Clinical Digest7

7/7/10
Mannion,Me,James,Danni,Clive,Bernie

Maybe the date should have alerted me that today would be a disaster. I nonetheless approached this rare highlight of my Ntcheu orthopaedic calendar with the utmost enthusiasm and hope. The reason for such excitement was a long awaited visit from the illustrious travelling Orthopod, Mr Steve Mannion and his highly committed team from the Feet First project, Bernie, Danni, Clive and James. Mr Mannion, aptly surnamed “superdoctor” by Lord Winston for the BBC, is usually based in North West of England, operating at the Blackpool Infirmary. Despite such proximity to my UK abode, our paths never crossed while I was there. We always seemed to miss each other. Not surprising when you consider his typical timetable, which is a sequential intercalation of 2weeks in the UK and 2weeks in some other part of the world, mending limbs and restoring vital functions! This routine sees him visiting Malawi up to four times a year, where he was one of the founders of the club foot programme. So, when I found out he was coming, I linked up to try and organise a surgical visit over at Ntcheu. This request was positively received and I went on from there to meticulously build an appropriate operating list for him. The task was no easy one, considering all the logistical hurdles this posed. Firstly, as at every district hospital maybe in Africa, maternity has first pickings on theatre space allocation. Therefore, I had to make arrangements, with the help of the DHO, for all maternity emergencies to be directed to our neighbouring district hospital on that day. I also had to make regular announcements at our handover meetings to remind everyone of this eventuality. Furthermore, I had to make sure that transport would be available for these transfers and that the transport officer was also at the ready. The job of ensuring anaesthetic and nursing cover for theatre on the day became a plea at times, where instead of (rightly) assuming that these people would simply turn up on time as they are meant to on any day, I had to entreat them do so like they were doing me a favour. But it’s best to play the game. So I did and it bore its fruit. Meanwhile, I put a paper request around all the potential points of recruitment for interesting cases, including our orthopaedic and outpatient departments as well as the physio outreach programme. This yielded 4 cases, 3 minor and one major to be done. With some kind of sixth sense, I at first told all the patients to come in 2days before the planned day. Then somehow, I got dissuaded from this by my colleague, who reassuringly told me that admitting them on the eve would be adequate. Little did I know that the eve would be a public holiday. What that effectively did was to completely sabotage the list. Only one patient turned up on the op date and, to make matters worse, it had been breastfed already, thereby delaying the only operation of the day! Fortuitously, that same morning there turned up a potential second case, a new one which presented in our clinic. All excited by this luck, we started preparing for the op. The patient, an old man with recurrent Dupuytren’s contractures, told us he’d go and lock up his bike and make his way to theatre thereafter. Again, as tends to happen a lot in Malawian hospitals, and escaping my all-too-informed vigilance, the patient simply did a runner! Did we scare him!? Did he just not want to have the operation anymore and live on with his rather debilitating deformity? Whatever the reason, our second case never materialised. So we did one single case, a tiny one indeed, a correction of a polysyndactyly at the fifth toe of a 7 month old tot. It was a great teaching case nevertheless, not just surgically but also from a nursing and general theatre planning perspective. Bernie, a senior theatre sister by profession, did a reckie of the entire department and came up with some pretty sound recommendations. The maintenance of sterility suddenly doesn’t seem like such a ludicrous concept anymore. Meanwhile Danni, a radiographer, had a productive session in our radiology department, providing that essential support this group of staff rarely gets here. Clive, ODP by trade, was our jack of all trades keeping the list on its feet (so to speak) and making sure all our equipment was there. James, baby doc just hatched out of med school, added a breath of fresh air, good humour and keen hands and feet to assist us with setting up the patient. He miraculously got a cannula in a 7months old’s hand, first time. Shot! Looking back, I realised that we managed to turn a seemingly disappointing start into a truly rewarding half-day. The time freed up allowed us to go around the wards, and for me to receive some feedback about patient management in the district context. It also allowed for a couple of highly useful presentations on specific management of a number of conditions I’m dealing with all the time here- skin grafting for wounds, femoral fractures, neck of femur fractures etc. Above all, it provided a real insight into the typical Malawian working style and patient attitude, which, if ignored in any enterprise like today’s, can leave you feeling pretty bitter and dejected. None of us did though, since, knowingly, we planned for the worst case scenario anyway. Today, certainly, was far from that! To brighten things up even more, I inherited a mouth-watering selection of surgical tools to supplement the rusty ones in our Ntcheu kit and hopefully open up new operating frontiers in the near future. What more could I ask for?!