The Sweetness of Victory

There have been a number of moments on this trip when I have considered the line to be particularly fine between ‘being up for it’ and ‘madness’. And at 6pm today as I entered the second hour of my journey, I was questioning which side of this line I had found myself! I was driving on my own, now down what was beginning to seem like an endless rutted mud track through the African wilderness, in the rapidly failing light (we had been strongly advised against driving after dark) in a borrowed 4x4 (that has over 300k on the clock and just had a puncture repaired – the reason why I left late) to join Kate and the girls for a weekend away – they had left this morning as it was a school off day. However, as I pulled up to the gates of the Peponi beach resort (literal translation – paradise or heaven), I breathed a proverbial sigh of relief and confirmed that what I had in fact done was an incredible mini-adventure driving through absolutely stunning scenery (and, perhaps, got away with it!). From the messages I have had throughout the day from Kate and the girls, a much-needed weekend escape to paradise awaits.

I arrived for dinner - it was stunning

For me, today has been great. The morning meeting was livelier than normal as the challenges of the case from yesterday were recounted at length. It was fascinating to sit in on the animated discussions that switched from English to Swahili and back again. Comments about me were generous and it is always nice to feel appreciated. It was then on to an eclectic ward round of the female ward, children’s ward and male ward. My practice here in Tanzania, whilst very different from the relatively specialist practice I have in the UK, is very interesting (and challenging, in a mostly pleasing way). On our ‘travels’ round the hospital, we found a strangulated femoral hernia that needed surgery and this was to be the case for the day. As it turned out, a fantastic case for the team, with the best example of a Richter’s hernia I have ever seen (a fairly rare variant of a complicated hernia). This was especially pleasing as it really consolidated the material we had covered in our meeting yesterday. And the team delighted in doing another bowel resection (albeit a very limited one). They were also very open with the fact that had I not been here, this probably would have been operated on as ‘an enlarged lymph node’ and I suspect that the patient may well have become very poorly when that tiny knuckle of bowel that would have been very easy to miss, perforated and caused peritonitis. 

You can see the needle at the start of the green

But the highlight of the day for me was to be found in an autoclave (a ‘cooker’ to sterilise surgical instruments). And that statement is something I would never have been able to even dream of saying before this trip. In trying to find a solution to the mesh problem, I had been taken to the stores two days ago to see if there might be a ‘Little Sister’ (type of autoclave) hiding in one of the containers that had come from Hereford years back. Instead however, we found a brand-new ‘pressure cooker’ type one that had been sent from India for a research project at some point in the past. I had done my research with Professors ‘Google’ and ‘Youtube’ as well as having had some very helpful feedback in response to an earlier blog post (technical things about pressures and indicative temperatures). So after the hernia case, we set it up and gave it a go. The first challenge was that the plug was Indian (of a type I have never seen before). Remarkably, a suitable adaptor was found! Then there was a little trouble in actually getting the other end of the cable to fit in the machine, but we managed and turned it on. It seemed to work. I had prepared another sample mesh and we stuck a piece of indicator tape to the envelope (black stripes appear if sterilisation is adequate). I then sat very patiently as it started to boil. Waiting, watching and waiting for the pressure needle to begin to rise. And then after about five minutes it did. Great. Slowly it crept up the gauge over another five or so minutes until it hit the start of the green zone. Now I needed the needle to stay at the start of the green zone (equivalent to 121°C) and not drift any higher as the mesh would melt. The steam started venting and it seems that this particular model had been set to run at 121°C. The temperature was holding. The 20minute timer was started and I began to feel optimistic that this might actually work. And then there was a power cut (of course there would be) – gulp – the needle started to drift just a touch but held in the green zone… and then the power returned. Phew. And then a few minutes later, the power went again…. but again returned. We reached the end of the cycle and vented the machine (extreme care required, I did not need a third degree burn, but all went smoothly). And then we opened. I could see immediately that the indicator tape had done what it was supposed to. And within the envelope… the mesh… was perfect! It was just as I had hoped and had shrunk the 10-20% or so that I was told it would (reassuring me further that the sterilisation process was indeed acceptable). I can not quite express how happy this made me feel. 

Sometimes, to really appreciate something, the struggle makes the ‘victory’ that little bit sweeter. Mesh hernia repair is a go.

1. Lifting the lid, you can just see the lines on the indicator tape. 2. The successful mesh below the three previously overcooked ones.