A boy to remember/a surgeon to forget.

sunset

As older professionals, whatever that profession is, we were all young and inexperienced once. So one must not be too judgemental of others’ mistakes. I used to tell my students that we all make mistakes, but, if possible, reduce your own by learning from the mistakes of others.

I mentioned in a previous post  When to leave the training nest? that, for a time, I visited and operated with/for a friend every Friday. One week I discovered that a second, just graduated surgeon had been appointed there. Neither my friend nor I knew anything about him, but as there were 2 operating rooms he suggested that we had to appoint someone upon whom the new chap should be the surgeon. Maybe one of us should have watched him, but we were in the other operating room, both involved in a complex case.

To divert – you can get hernias in many places but the commonest are in the groin or at/near the umbilicus. A rough, workable definition of a hernia is a bulge of an organ (or part thereof) through what normally contains it. Basically three words are used in describing the way you repair a hernia.

  1. Herniotomy – the simplest of the three, where you push back the contents and just cut off the sac, which is usually a bit of peritoneum. This is the common way of repairing a child’s groin hernia.
  2. Herniorrhaphy – where you sometimes include a herniotomy but then try to repair back to normal anatomy.
  3. Hernioplasty – wherein you sometimes do the above but try to strengthen things by rotating something or adding some foreign material, usually some sort of plastic mesh.

We chose for him to operate on an about 8 year old boy with a common type hernia on which you did the simplest of the three repairs above, in colloquial language, it should have been a cinch. He did his operation and the boy was sent back to the ward.

On the next morning, while seeing my patients from the previous day, I came across this boy, screaming in pain and in obvious great distress. He had an exquisitely tender mass extending from his umbilicus to just above his right knee.

He was not my patient and I was not the head of surgery. So I asked my friend to contact the surgeon who had operated and ask him to see his patient. The guy didn’t answer his phone. I needed to go, so I suggested that my friend try to ring again in about an hour but that if didn’t come that my friend would have to re-operate himself – he was very capable to do that. The guy answered the next time, but refused to come; my friend operated. The top of the bladder had been cut off and left open, so the mass was all urine.

I’ve never heard on any occasion of such a thing happening. Can I forgive him? As I said at the beginning we all make mistakes. I find it very hard to understand this mistake, but certainly I don’t forgive his refusal to come when called to review his patient.

The kid recovered, but instead of a day case, his recovery took quite a while.

I have at least one follower who hates medical photos so BEWARE below the line. Continue reading “A boy to remember/a surgeon to forget.”

Bites 2 – continuing the list.

Monkeys – we didn’t see a lot of monkey bites. There are of course many different types of monkey. In one place where we lived there were dozens of them. We had a lot of bananas but, against what we expected, they rarely ate them. They loved our guavas. There was a large tree abutting the back of our house. They would steal as many as they thought they could hold, run along the roof ridge and, no doubt accidentally, dropped some as they ran. Those dropped would clatter down the tin roof into the gutters; which was annoying, particularly at night! They would sit on the window looking through the bars, and you wondered who was looking at whom!

monkey
Who’s watching who? -At our kitchen window.

Guereza monkeys, brilliant with their black and white colours, leaping from tree to tree were gorgeous to watch. Staying for a break at the one of the Rift Valley lakes we saw lots of those monkeys with ‘painted’ backsides. They were thieves, watching carefully and awaiting the moment, they’d jump down and steal food from your table or even your hand.

Hyenas – people think that these are only scavengers, but they are prepared to attack living animals or humans. They can cause rabies. At night time our workers would not walk alone. There were always at least 2 or preferably more of them and armed with dullahs (heavy sticks) when walking outside..

The two cases which stand out in my mind are of two boys who came in (at separate times) both having been scalped. (photos below the ‘more’ line) The bone on the top of their heads was laid bare over many sq cms. You cannot graft onto bare bone. We had to drill multiple holes through the outer table of the skull, being very careful to not go right through the inner table of bone. The tissue in the centre of the bone (the marrow or medulla) granulated out through these holes and when it had covered the bare bone totally we could skin graft it. Both boys eventually did well even if they were prematurely bald, and needed to wear protection to protect their grafted skin from trauma and the sun. Thin (split) skin grafts don’t become normal skin again.

Wild boars (called kekero there). With their long tusks and bites they could tear skin and do a lot of damage. We had some that visited us daily in our garden. They learned how to turn on the tap in our back yard using their tusks – in order to get a drink. I wouldn’t have minded if they had only thought to turn them off. The locals told us when we arrived at that University that rhinoceroses came every afternoon. They got it wrong. We never saw a rhino but daily had boars visit us.

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Crocodiles  are very common in the Rift Valley lakes. Crocodile teeth tear the skin and shatter the bones. We saw a lot of their bites as the people fished from very flimsy balsa wood boats.

croc

Hippopotamuses- I clearly remember a number of hippopotamus bites, all very dramatic. The story of one boy is fascinating. The villagers were short of meat and decided a hippo would be good meat. Half the village got behind him and half on the other side; many with spears. Those at the back began to drive it forward. It began to move. The others were ready. The hippo saw them; didn’t like what he saw; began to charge at full and frightening speed. The villagers fled but this boy slipped and fell; the hippo was on him. The villagers killed the hippo and probably enjoyed the meat. The boy was brought to the hospital. He had a big gash on his chest, exposing but not breaking his ribs and a cut slicing his left buttock in two and the cut extending to the back of the knee. It was deep enough to expose the sciatic nerve, over a long segment, but did not divide the nerve.

hippos
We didn’t like getting too near hippos – they charged at you.

Another hippo bite that comes to mind is when a woman was leaning over near the edge of a lake doing her washing. A hippo came up behind her and bit her buttocks from top down laying them as if it they were an open purse. Fortunately  it was mainly skin and fat and was repaired fairly easily.

Dominic Cartier

Some hyena bite medical pictures below the line Continue reading “Bites 2 – continuing the list.”

The extended work – part 2

African sunset

I have posted previously about my time working in a leprosarium.   Working in a leprosarium 1968-74  And about a non leprosy medical work. The leprosarium extended – part 1 I mentioned there that was more to this other side of the non-leprosy work beyond the medical work.

The Other works for the general community consisted of the following….

A school with an enrolment of about 600 for the surrounding community. This only went to grade 8. A significant number of the pupils were mature age coming to school for the first time to learn the 3Rs. So in grade 1 you might have a six year old sitting next to a 21yo. Teachers were in such short supply that after 3 years as a student you had to become a teacher for a year, before returning to your studies. It seemed to work. One student who went to the leprosy school is now a professor of surgery!

A church with associated outreach. We were in Muslim poorly educated area. So many of our workers in all departments were people from different tribal areas and most were Christians. So the church was several hundred strong. They didn’t have hymn books but many, not being able to read,  had developed their ability to memorise. So they had a wide variety of hymns of which they could sing a number of verses. I remember how if a baby would continue crying the preacher would say “haven’t you a breast, woman?”

There was a small administrative unit consisting of the station head and a secretary. They among many other things supervised an electricity generator as often the government service failed. This was a major problem if we were operating at the time the electricity went off line. Operating by torch light while you waited for the generator to be turned on was not fun! But we always kept one handy.

There were mission and government reports to be written, wages to be paid, equipment, medicines etc to be ordered (much of it from overseas, and months in advance). I’m glad someone else had to do it! Continue reading “The extended work – part 2”

The leprosarium extended – part 1

African sunset

I have previously posted about my time working in a leprosarium. Working in a leprosarium 1968-74  I mentioned there the other side of the work carried out on the same station. As leprosy only rarely has acute problems I spent most of my time in the non-leprosy part of the program. I only regularly spent 2 half days/week with the leprosy program, besides seeing the occasional emergency in the leprosy department.

Other work for the general community – this post will only discuss the second non- leprosy medical work. There were several other aspects for another day!

There was an (officially) 30 bed hospital with an added 12 bed TB ward and an attached outpatient clinic.

It was the only hospital covering a large area and several million people. Through the country there were scattered clinics run by dressers (they were not to nurse standard but with some training, and had permission to prescribe a few simple medications) and a few mission clinics but the nearest hospital south was about 80 km away; north 200 km; west 150 km; east several hundred km, and this in a heavily populated, very fertile, part of Ethiopia. We were at the cross roads which led in all 4 directions. At that time cars were few and far between and public transport was limited. As loaded trucks often carried many people on top of their loads we often had mass emergencies if there were major accidents. And there often were!

It really wasn’t beds for just 30 patients. We used to put smaller children one at the head and one at the foot of the bed. In times of great overload we used to sometimes put patients on mattresses under or between the beds. There were verandas on the east and west sides of the main building and we would spread mattresses on them. Sometimes in the rainy season there would  be a rush to change the ‘veranda’ patients to the other side away from the rain slanting in from one direction or the other. Most people chose to go to the clinics or to natural healers before a percentage came to us. We could never have survived if all those who should have, had come!

This general hospital had a small ‘operating room’ which was mainly used for obstetrical deliveries which needed forceps deliveries. More major cases, obstetric or other general cases, were taken to the OR in the leprosy hospital. We had few normal deliveries apart from the wealthier women from the nearby moderately large town. For a normal delivery they were charged about ten times as much as a poor person with a complicated pregnancy – something about robbing Peter to pay Paul. Unless there were problems after delivery these ladies were allowed to stay about half an hour.

The room was also used to reduce simple fractures and for suturing. The leaded room with the X-Ray machine was attached to the hospital. The machine was an old WW2 field one. A local young man was trained to take the simpler X-rays. See an example of one of the chest X-rays below.

In addition to the 30 beds there was a 12 bed TB complex. TB was very common. Only the very weak or those with complications, like lung collapse or paralysis from TB of the spine, were admitted. Another national worker was trained to aspirate chests and put in chest drains.

The  outpatient department was in a separate building. It included our small pathology department. We treated about 100+ cases a day. Apart from acute emergencies, who were sent directly to the emergency room in the hospital, all were seen initially by a dresser. If they couldn’t make a diagnosis, or if the patient returned with the same problem, they were referred to the nurse. If the problem still remained the nurse arranged for them to see the doctor sometime. I, or if there were 2 one of us, tried to visit outpatients just before I/we went to lunch.

Emergencies were common. I remember one day when 3 ladies with ruptured uterus came within 5 minutes of each other! As well as daytime surgeries, planned or emergency ones, many emergencies arrived out of normal hours, so we operated most nights as well on emergencies.

The 4 nurses had the following duties: One was in charge of the general hospital; one of the leprosy hospital including the OR; one in the leprosy outpatients; one in general outpatients. If we had 5, the fifth was on night duty for all the work – if there were only 4 they rotated around taking responsibility for both parts of the work at night. They were very competent and really acted as junior surgical registrars.

Below the more line is a picture of a chest X-ray of a TB patient. Continue reading “The leprosarium extended – part 1”

Working in a leprosarium 1968-74

African sunset

I have posted before about our first day in the hospital on our first spell overseas. An introduction to Life in Africa The establishment had a large complex of programs run by a Christian mission. It was on land given by the Emperor’s daughter and it’s distinctive feature was that it was to have a large leprosarium. This was in a period where the concept for many including the government was to keep people suffering from leprosy (Hansen’s disease), certainly those with the infectious variety, apart from the general populous.

The government gave a grant to the mission to help treat 700 patients residing on the land already granted to them. Nearby there was another parcel of land given for the mission to produce food to feed the leprosy patients living on the leprosarium.

The mission took this work very seriously and expanded way beyond just keeping lepers off the streets and treating them in the relatively limited ways available at that time. The work of Drs Cochrane, Brand and Fritschi, basically in India, with their teams had made much progress but treatment was not as available nor efficient as it is today. India was much more developed. I had some time in India with Drs Cochrane and Fritschi on my way to Africa.

The local tribal language was what is now called Oromepha. The greeting was ‘Nega, fiya, urga’ roughly translated ‘hello, how are you? It’s nice to smell you.’ The last bit sounds nasty. But the verb really had broader meaning, including to sense, and I think the intent was something like ‘it’s good to sense your presence’. But because of the use of rancid butter smeared on clothing to make it waterproof, added to smokey fires in houses without chimneys, there was often a fairly powerful smell. When I had been working in the operating room where, in addition to the above, we used a lot of ether for anaesthetics, I personally collected some of the odour. Many times when I got home to greet my wife, with a loving kiss, I got told ‘You stink, go and have a shower.’

Early in our stay, I remember introducing my young son to a lovely bright young man who had come to visit me. The man knew good English. The boy greeted him politely then turned to me and said ‘Dad, do all Ethiopians smell like this?’ The guy was very gracious saying something about kids being like that everywhere!.

The compound had 2 parts. That devoted to leprosy treatment and that for general service to the surrounding community. Today I’ll write about the leprosy part of the work. The general service to the community aspects were almost as extensive! Continue reading “Working in a leprosarium 1968-74”

Beware…

hospital plan

This is a medical post. The above is an elaborate scheme for a designed new hospital to replace the one built initially as a mission hospital by the Norwegian Lutherans. The design had  many basic faults.  Hopefully they listened and incorporated some changes. It should be opening soon and I trust it will work well. You may note the expected completion date (in our calendar 2017) it was hardly started by then!

You may not want to read beyond the ‘more’ line as there are some very interesting but a bit gory photographs. You can see worse on TV.

I almost  always lived and worked in the southern part of the country, between  250 and 500 km from the capital. I had taught briefly in the capital, but that was where the vast majority of the nationals sought to be, so I usually worked down country.

Interestingly I had a postgraduate surgical trainee come down from the capital, as a patient,  where he was working in a major teaching hospital for surgery on himself. He brought his own anaesthetist with him. The anaesthetist went to church and prayed while I operated on his colon cancer and my guy gave the anaesthetic. Follow up on Mesfin of the ‘3 Teenagers’

Another man come from the capital of a neighbouring country. He had drunk lye and had a very narrowed scarred oesophagus. He had an oesophagectomy performed and his oesophagus replaced with a piece of colon. We didn’t have a physiotherapist, so essential in the postoperative care of such patients, and I gave a crash course to the servant (slave) he had brought with him. The patient and the servant did well and the patient wrote to me yearly for several years.

But the case I wish to write about today is a man whom I met on arrival as a new professor at a down country University Hospital. He was a poor man with a huge scrotum. When he stood up his scrotum nearly touched the ground. When weighed, after excision, it was 30 kg. There were 2 trained surgeons there but they weren’t prepared to operate on him, even though they were quite senior.

  • It looked gross.
  • He was hardly able to walk.
  • His penis was buried inside the mass, so that when he urinated it was a mess.
  • Although married sex was not possible.

The cause was tuberculosis of his groin lymph glands and if you look at the photo later, you will see that his left leg had begun to swell as well.

The condition is called lymphedema and occurs because the lymph cannot drain back through the diseased nodes which are blocked by the disease. In his case they were affected by TB. Lymph is part of the blood carried out by the arteries which is filtered through the tissues and returned through the lymph channels  higher up back into the veins. It has no blood cells in it but is a second return system running parallel in function to the veins. The volume drained as lymph is much less than is returned through the veins. In other words the volume carried out by the arteries equals the volume returned by the veins and the lymph.

Of interest are the following….

  • The shaft of the penis is not involved in the swollen diseased state, although its skin is.
  • If the patient hasn’t been circumcised the skin on the inside of the foreskin is not affected in the disease and can be used to help cover the penile shaft when closing the defect after excision. This man had been circumcised.
  • The testicles also are not involved in the disease but the spermatic cord is often very elongated, as the weight of the scrotum pulls the testes down.

So the aim of the surgery is to dissect out the penis and testicles without damaging them; excise the abnormal tissue; cover the defect – creating a new scrotum and covering the penis with skin, often using skin grafts.

Photo 1 shows the patient lying on the operating table prepared for surgery. As he had to be prep’d from the umbilicus down to his feet on the front and back, it was done with him awake and standing up. You will perhaps note the left leg has begun to swell.

Photo 2 shows the penis dissected out before the mass is excised.

Photo 3 shows the dissection complete and awaiting repair.

Photo 4 shows the excised scrotum, which weighed 30 kg.

Several days after surgery I asked him if he had had an erection. With the broadest of smiles – the frustrated young husband said “yes”.

Looking through my photos preparing for this I noted that my first assistant was a postgrad student, who is now working with the Red Cross in South Sudan. He’s a very good young surgeon. After his grandfather died he appointed me as his new g’father replacement.

The photos are below the line. Continue reading “Beware…”

Follow up on Mesfin of the ‘3 Teenagers’

boy's home
The home in which Mesfin grew up.

Mesfin, Tadessa and Solomon all have fascinating stories beyond what was written in A house full of teenagers. Mesfin was the first to come to us.

In countryside areas of Ethiopia birth certificates were not issued at that time when children were born. You could buy them and supply the details which you chose to have put on them. So it is a guess as to how old Mesfin was when he came to live with us. He didn’t know his birth date either, it not being the custom to celebrate birthdays; so we appointed my father’s birthday as his and guessed that he was maybe 16 or 17. I am writing this on his ’41st’ birthday! He was in grade 9 in the local high school. Schooling was for half a day – one group of students had classes in the morning and a second group had class in the afternoon. They alternated from morning to afternoon weekly. There were so many kids to be educated, and this arrangement allowed each school to double its intake! Mesfin was bright. He had a cocky, cheeky nature but was delightful and wanted to learn. His English became very good with an Australian accent. Continue reading “Follow up on Mesfin of the ‘3 Teenagers’”

A small taste of what will be a bigger post one day…

standard thyroid 512As I understand, the world record for the weight of a thyroid is 13Kg. This example maybe slightly more than a Kg which still weighs much more than the normal about 20Gm.

I previously wrote about an interesting case in A sad but interesting case. Being very mountainous there was a high incidence of goitre which unlike the reported PNG experience did not respond to simpler medical regimes and often required surgery. We used to list the common indications to consider surgery as

  1.  difficulty in breathing or swallowing
  2. enlargement into the chest
  3. Proven or Suspected malignancy
  4. controlled hyperthyroidism (over action)
  5. cosmetic.

The marks on the neck are from the application of national herbal medicine. It didn’t seem to help.

After 300 such procedures I wrote a paper. There was a 15% incidence of small malignancies in the very large glands. But we’ll leave more for another day!

malig thyroidThis small thyroid in a young teenage boy proved to be malignant. The post grad student in the picture has become a famous surgeon.

Dominic Cartier.

An introduction to Life in Africa

African sunsetAfter obtained my higher surgical degree I spent six months in India before going to Africa. Like a good boy I was up to date with vaccinations and all those necessary things before I left for India. I was ready for my life in Africa!
We flew along the Arabian coast line at the same speed as the day was starting – travelling East to West. All the way the sun shining on the cliffs was magnificent. Flying into Addis Ababa was green and so much like Australia with all the gum trees. Our two young boys were able to stretch out and sleep all the way from Karachi, which was bliss for us.

The landing was smooth; the passage through Immigration was not. Well, it was for my wife and the two boys. They were allowed through, were met by the mission heavies and taken to where we were to stay, whereas I was arrested. I was put into quarantine because my cholera injection was one day over the six months expiry time. All my arguments fell on deaf ears. My wife and the boys had had no problems in entering as they had joined me in India several months into my stay there and had their shots just before they left.In the quarantine station  I met a Greek (I think) doctor who agreed with my very logical argument that the injection is not 100% effective and the six months is not exact to the day. He gave me a booster injection and sent me to where my wife and children were.
While not being usually very tearful, having been told that I would be sequestered for six weeks, she was crying buckets full. Tears rapidly turned to joy.
We had a few days to acclimatise before we were due to head south to the place I was to work. We had needed to buy five years clothes, kitchen stuff, linen etc.  The two growing boys would need a lot of extra clothes. Things were very different in Africa 55 years ago and few things were available in the shops. Hospital expected requirements had to be ordered 6 months ahead of their needed date. We had planned to stay for 5 years. So, although we flew, 16 boxes had been sent ahead by ship.
We had to go to many offices over a couple of days to get it through customs but we were not charged duty. Foreign workers were very welcome at that time. There were 300 doctors for 30 million people and few of the 300 were trained surgeons.
Ten days after arriving in the country we were taken down to the hospital in which I was to work. There was a leprosarium with 700 inpatients plus an outpatient service. Many lepers had moved into the surrounding area as we were the only leprosarium in the southern region. There was also a 30 bed general hospital with an outpatient service with an average attendance of about 100/day. There was one doctor, 5 trained nurses and many national workers, including a number of trained dressers. Some other time I might say how we managed it all. I was to replace the one doctor who was leaving in 2 weeks on a years break.
We arrived at 3 in the afternoon. The doctor’s wife gave us afternoon tea. The doctor had some emergencies which he wanted me to see – as they needed surgery immediately!
We got home for supper at midnight having seen a number of patients and performed 3 operations. Two of which I recall – an urgent Caesarean Section and a bowel resection on a 16yo girl with a large mass obstructing the right side of her colon.
That was the start of a marathon run lasting several years.

double use of OR 2

Please don’t comment on the masks. I had operated on the patient seen in the background and was just preparing something on the second patient – a child – he too was asleep. Due to lack of staff to watch people adequately we sometimes ad even 3 patients in the OR. One being operated on and the others(s) being observed. From the greyness of the sideburns I can tell this was in my second trip. On the first trip – no grey, then white sideburns, then eventually all white! (I cut the kid out of the picture as he was not appropriately dressed).

Continue reading “An introduction to Life in Africa”

A sad but interesting case.

morning sky 1We live in a beautiful world. Some times we wake up whether it be from a sleep or an anaesthetic and find that today something isn’t quite right. I guess that it is almost a daily experience for many at the moment as they awake to the restrictions of the coronavirus business with associated problems. Maybe the worst of which would be the death of a relative and realising that you are forbidden to mourn in public. The girl whom I am discussing now woke up from an anaesthetic, to face the realities of a very different life. Continue reading “A sad but interesting case.”