A boy to remember/a surgeon to forget.

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.

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.
Herniorrhaphy – where you sometimes include a herniotomy but then try to repair back to normal anatomy.
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!

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.

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.

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.

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.” →

Bites 1 – garden and domestic

boars — These are some of the ones which came into our back garden and who could turn on taps!

We all get bites at some time or other.

Insects bite are probably the commonest and they cause lots of problems. There are thousands around the world who die every year from malaria. The enlarged spleens which they often get make them more prone to getting ruptured spleens from traumatic episodes. There are also other nasty mosquito spread diseases. Ticks also bite and they can cause a variety of diseases. Scorpions – their stings cause severe pain but usually not much else. Young children may get worse reactions as a few varieties are venomous. Injecting directly around the site with morphia gave the quickest and best results. You quickly had very happy customers. The above almost always cause medical diseases although there can be complications requiring surgery, and I’m a surgeon – so I tended to deal with bigger mouths and more traumatic bites.

Snakes – Their bites are not consistent in how they behave; that is they are either venomous or non- venomous, and there are a variety of venoms. The non-venomous just give you a nip without poison – scary but these are really a fairly minor issue. The venomous ones have a variety of ways of causing major problems. Among them are neurological problems, bleeding diatheses, tissue death, allergic reactions, kidney failure. It is nice if you have specific antivenins available depending on the type of snake, but our patients tended to arrive late, and antivenins are much better if given early. The polyvalent antivenoms which we held in stock were not as good at any rate. The major problems we saw were of tissue damage with massive swelling needing splitting of the skin to relieve pressure, and often cutting away the dead tissue. Amputations were occasionally necessary, but more often we could cover the dead areas with skin grafting. Continue reading “Bites 1 – garden and domestic” →

The extended work – part 2

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” →