…is sometimes what practicing surgery in Kiwoko Hospital feels like. For someone brought up in the UK healthcare system, where almost any investigation can be carried out (albeit sometimes with a long wait – oh dear, I’m getting political!), the lack of facilities here in rural Uganda makes treating patients fairly interesting.
We can do basic laboratory investigations on blood, but each test costs the equivalent of £1 or $2 – which starts becoming unaffordable for our population if you suggest too many. So rather than getting routine haematology and biochemistry on every admission, we may request a Haemaglobin level to check for anaemia, a white cell count (done manually by microscope), to look for signs of infection and likely type of causative organism, and sometimes a Potassium level or renal function tests.
Our radiological investigations are similarly limited. We can do plain x-rays (of adequate quality) which cost about £1.50 each, and we have a portable Ultrasound machine – if you’re prepared to try and use it yourself: in the UK all ultrasound exams are done by radiologists, so I’ve had to learn on the job what I’m looking at! Other more complicated examinations such as dye-tests on the kidneys, contrast studies for bowels, and CT scans (3D x-rays), are available in Kampala – 2 hours away along a very bumpy road – but are usually too expensive for our patients, costing upwards of £20 a time (a CT scan is £15!!!). The other factor in our x-rays is that we have variable availability of electric power – if we have no mains electricity, urgent investigations have to wait until 10am the next day when the generator comes on for a few hours.
I’ve managed to improve our bowel investigations from non-existent, to now being able to visualise the inside of the stomach or lower colon. The equipment I’ve managed to acquire over the last six months has resulted in us having the facility for endoscopy – fibre-optic examination through a narrow tube, and this has been enthusiastically received by the local doctors who are very keen to be taught how to use it. We’re limited at present by the 60cm length of our endoscope, but would love to get hold of an actual gastroscope (90cm) to extend the amount we can see!
I’ve had three patients this week for which I would have loved to have had better facilities, but instead ended up going straight for an operation – well, operating is what us surgeons do best! The first was a 7 year old boy who came in with three days of bowel obstruction followed by the passage of a little bloody stool – classical signs of intussusception even if he was a little old for it. No x-rays were possible, but small bowel loops were visible through his abdominal wall, so he needed an urgent operation that night. I actually found he had a hernia of his large bowel through a defect in the right side of his diaphragm into his chest, which had blocked and become necrotic. Not something I’d ever even heard of before, but I was able to resect part of his bowel, close the hole in the muscle and place a chest drain. Would an x-ray or CT scan have helped? I might have known what to expect before I started, but I suspect I’d still have done the same operation.
Second was a 30-year-old man who had perforated an ulcer ten days earlier and had been operated on by one of my colleagues. He had developed pneumonia, had some fluid in his abdomen, and he was being very slow to progress. We sampled the fluid and it did not appear to be infected, but it would have been good to get either CT scan or contrast x-rays to see if his ulcer was still leaking. Going back for a look in theatre was not a good option because of his pneumonia. Unfortunately his wound burst open, necessitating a trip back to theatre where I carefully drained the fluid and confirmed that the patch on the ulcer was still in place. Again, this was a situation where more information might have helped with the decision of whether to operate again or not.
My third patient was an elderly lady admitted with bowel obstruction for the previous week who was very dehydrated. X-rays might have helped determine the level of the blockage, and a contrast enema might have shown whether it was constipation or a physical lesion. Without these confirmatory tests, the obstruction had to be relieved, so I operated. The actual obstruction was in the middle of the small bowel, which was full of constipated stool (usually only seen in the colon). The obstruction was not a physical lesion but a bolus of firm bowel material that was moving very slowly, but showing all the appearances of a blockage. I think this lady would still have needed an operation, as even with investigations it would have seemed to be a small bowel obstruction.
For all three patients, the decision to operate was made on the basis of the story and examination. Investigations would make the job easier, but ultimately I think all needed their procedures, and I am pleased to report are all well on the way to recovery. These sorts of decisions are the ones that cause the stress of being a surgeon here – who you operate on, who will get better without an operation, who will die if you do operate… It’s tough, but in the absence of any alternative, I hope that I can continue to try to do what is best for the patient. In many ways, it will actually be hard to go back to the defensive practice of over-investigating patients once I return to Scotland in January!
I pray life may be fairly stress-free for you wherever you are just now!
Steve
