I’m sitting in my house watching a completely tropical downpour here at Kiwoko Hospital in Uganda. Although there hasn’t been too much of a wet season, and we’re now supposed to be in the dry season again, when it does rain it can be spectacular. So water is currently flooding over the deep gutters, and there’s a river running through my garden! I’m told that there’s been flooding throughout the UK this summer – perhaps things here aren’t so bad: I suspect in another hour or so it’ll be bright sunshine again! Everything stops when it rains here – so it’s a good thing that I’m having a quiet day today… it was a different story last week.
I must have operated on about twenty patients between Wednesday and Friday. There wasn’t a huge variety, but the majority of cases were quite big surgery. For some reason I had about six women all with some form of pelvic abscess requiring drainage. Two of these required their appendix removed at the same time (primary cause – not able to distinguish between appendicitis and salpingitis, but appendicitis is pretty rare here). There was also at least one large ovarian cyst.
So on Wednesday I managed to see all my patients before 8am, and was able to get started in theatre early with two laparotomies and a large hernia before lunch. Then there was a broken elbow to put in plaster, a deep wound in a heel to debride and resuture, and finally some skin grafting in the afternoon. I was especially pleased with the result of my skin grafting, as I haven’t done this operation in the eight years since I was a junior plastic surgeon, and even then it was under very close consultant supervision. My patient on this occasion was an elderly lady who had lost a large area of skin over her left shin as a result of chronic osteomyelitis, which had now been treated well. I’ll be taking the dressings off in a couple of days to see how well the skin has taken, but I’m very hopeful of a good result.
If Wednesday wasn’t busy enough, I had another three laparotomies on Thursday morning. We were just about to head for lunch when Dr Louis (a new Ugandan doctor) told us we had an emergency Caesarean Section – he isn’t able to do them without supervision – so I stayed and helped him with a woman who had had a significant pre-delivery bleed, and whose baby was showing signs of distress in the womb. He did a good job, and we were reasonably quick, but then there was another woman who was in labour and had had two previous Caesareans, so things would burst if we didn’t operate again. I did this one myself, and unfortunately reached inside the abdomen to find a free-floating dead baby and placenta with a uterine rupture. This woman was very lucky to survive, and it became apparent that she’d ignored the advice to have her baby by Caesarean in hospital and had instead been labouring for three days in an attempt to save money. Tragic.
Then there were three women who had had early miscarriages and required evacuation of blood and products from their uterus, and a huge neck abscess to drain. Later in the evening (I was on-call for the hospital on Thursday night), I also had another laparotomy for a woman to wash out and drain widespread peritonitis (pus in the abdomen) probably as a result of PID. So Thursday had about six major and four minor cases – and Dr Peter was away in Kampala, so there really was just me to do it all!
My biggest case of the week took place on Friday (fortunately the on-call was not too busy overnight, so I had managed a few hours of sleep). For once I was doing an operation within my normal specialty – a cholecystectomy and bile duct exploration for obstructive jaundice. Ultrasound scan had shown two large gallstones wedged in the bottom of his bile duct resulting in back pressure into the liver and making him yellow. Without laparoscopy (keyhole surgery), I had to remove his gallbladder through a large abdominal incision, and then I opened his bile duct to try to remove the stones. We don’t even have x-ray available in theatre, so I wasn’t able to see exactly how stuck they were, but I was unable to move them or even bypass them with a fine catheter. Back home in the UK we’d have closed up after leaving a drain for the bile, and tried to retrieve the stones by ERCP – getting them out through the stomach with a fancy endoscope – but I don’t think this is available even in Kampala. I decided I had to do a definitive procedure to relieve his jaundice, so I brought up a bit of bowel and joined it to his bile duct to bypass the obstruction. He seems to be doing well, so I hope my improvisation should work – I’ve never before even seen the procedure I attempted, but the principle seemed to be correct. I’m sure if any of my bosses back home are reading this they’ll be horrified!
So as you can see, I’ve done very little this week except operate – thus the fairly surgical slant to this blog. I know some of you were missing the medical instalments of life as a surgeon in rural Africa! For those who prefer slightly less gory detail, I apologise, and would like to say that I managed to get away to Kampala on Friday evening for a great Thai meal, a good night’s sleep in a decent hotel, followed by a successful shop on Saturday, and even the latest Harry Potter film in the cinema on Saturday afternoon! It’s not all work and no play, although the balance could be better sometimes!
Anyway, the rain is abating, so I’d best go and see what new patients we’ve acquired since this morning.
Steve
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