This is why I’m here.

Today was pretty full on. Exhausting to be honest. But ultimately immensely satisfying.

The morning was dominated by difficult cases (all of which I had been asked to review after the morning meeting). Firstly, a man with possible oesophageal cancer, unable to swallow and coughing up very offensive sputum – to be honest, this was fairly straight forward from a decision-making perspective – he was sadly clearly heading down a palliative pathway (going to die).

Then a man who had developed progressive hoarseness of voice over two months; I’ve never heard stridor like it (stridor is a hugely concerning clinical sign that implies the airway is soon to occlude, sounds a little bit like Darth Vader). But what to do? With limited tests and no fibreoptic laryngoscope, it was best guesses. He had slightly improved with antibiotics, but to my mind, clinically he either had a laryngeal lesion (throat cancer) or a laryngeal nerve palsy from something like anaplastic thyroid cancer (a type of thyroid cancer that can destroy the nerves that supply - and keep open - the voice box). Either-which-way, with no ENT services available to him (travel to the capitol was not an option - money) it was a case of some adrenaline nebs, steroids and see what happens. Whilst technically, I could do a tracheostomy, it did not seem like the ‘right’ thing to do. Not least as I am lacking the required ancillaries and there is no specialist aftercare. My gut feeling is he is probably not going to do well.

Next a lady I’d seen the day before with a probable appendix mass – I’m treating her with antibiotics. But without a CT scan, I can’t do much more than hope that it is not in fact a caecal cancer. If she doesn’t improve by next week then perhaps a laparotomy…. Finger crossed because I predict that that would be a mess (“mess” is a ‘technical’ term for a very challenging operation!).

Then a Masai tribal boy (so neither he nor the family spoke Swahili) referred to this hospital to see me (within a week I have become a specialist orthopaedic opinion apparently) whose history said progressive swelling, pain and reduced function of the left leg over two months (but without trauma). He had an incredibly tender, deformed and obviously fractured femur to me (the XR later confirmed this). But might it be pathological? Probably. He has been referred.

And then a 14yo boy admitted the day before with abdominal pain but testing positive for malaria. When I examined him, he was overtly peritonitic to my mind. But tricky. Very tricky. And I found myself in a very difficult place clinically. It felt very, very uncomfortable. Is this malaria, or is that just a ‘red herring’? And with no other tests available (no WBC, no CRP, no CT, no specialist USS) it was all down to my clinical judgement. I needed to decide whether to watch and wait or perform a laparotomy (laparoscopy – key hole surgery – is not available here). A big call and no one here to share it with or ask for advice. I decided to give myself some thinking space and headed home for lunch (our house is literally at the hospital gates). Dr Google was very informative and Dr Karylin and Richard responded to my Whatsapp message with a phone call. Cant quite put into words how amazing that conversation felt, not just clinically but emotionally as well – at times it can feel quite isolated here estranged from our usual clinical support network. It also filled lots of gaps in my knowledge about malaria – apparently 25% of the population test positive for the parasites but most are asymptomaitc. So, when I went back to review, and he was clearly not better, he went to theatre. I will describe the theatre experience in more detail another time, but on table he seemed to have a central mass, so I elected for a limited lower midline laparotomy. I can honestly say that I internally breathed a huge sigh of relief when I discovered the cause of his troubles and that a laparotomy was absolutely the right decision. Always a big call in a child, but the right one. He had a small bowel intussusception (when the small bowel telescopes in itself – quite rare) and when I tried to reduce it, the interssuscipiens had clearly infarcted (that bit of bowel was dead). It may be surprising to read that at this point I felt very relaxed, I could almost have been back in the UK, and eased into performing the small bowel resection that was an absolute delight to the theatre staff. They have not tackled pathology like this for several years. The case went well and as I left for home, rather exhausted to be honest, it felt like an important moment in my time here. 

I will definitely enjoy a beer tonight!