Childs play?

 As I child I remember being a big fan of Blue Peter. I always loved to make things and enjoyed the various projects that they would periodically demonstrate. I always wanted a Blue Peter Badge, but like many I suspect, never managed to actually get round to ‘applying’ for one. Today however, I think I might have achieved my African ‘Gold’ Badge – perhaps a golden ship on a background of green, blue and black (the Tanzanian flag)…

Working in a hospital such as this in Africa requires a certain amount of adaptability. Of the like that would probably be considered completely unacceptable in the UK. Whilst it is challenging, there is also a certain amount of ‘naughty’ pleasure in ‘breaking’ the normal rules and making do. Testing your ingenuity. Searching for solutions to problems. Looking for a way to achieve something with only very limited resources. There is a price to this pleasure though, for as a surgeon you invest a small part of yourself to every operation you perform. You hope that your investment will pay off, but if it doesn’t, the pain is very real and very personal. It takes a while to get your head around working in an environment like this. From one perspective, it would be very easy to feel like the job you were doing was sub-optimal, below your expectations, hampered by the environment and equipment. Looking at it another way, you can still strive for excellence, just accepting that the limit of what can be achieved might be lower. My approach has been to try and emulate what I would do in the UK. Regardless of the fact that the instruments are limited, the sutures are not what you would chose to use (often actually inappropriate the job in hand – round bodied, cutting etc), the lighting is not brilliant and things like suction are often just a piece of large rubber tubing. Not to mention the power cuts! But it is possible, or close to at least.

Today I took on a Warthin’s tumour. This is a tumour arising at the angle of the jaw, just below the ear lobe and an operation that would be performed by a ENT surgeon at home. I had done ENT as an SHO and loved it. I had done my share of tonsillectomies, grommets and even a few tracheostomies. I had also done quite a few neck dissections – carotids in in my vascular jobs and a number of thyroidectomies. I had been involved with a few parotid operations but not as the primary surgeon. However, I had been presented with a member of staff who was desperate to have this lesion removed and, like for so many, going elsewhere was not an option. It was mobile and had grown over a number of years. I did some reading, corresponded with some friends at home and took the case on. It was very difficult, but it went well. I definitely had a few sweaty moments imaging all the structures I was trying to avoid would just happen to be between the blades of my scissors. And at the deepest part of the dissection, we were a bit too close for comfort to the main blood vessels in the neck that supply the brain! Out here, there is a lot to be said of a bit of experience, sound knowledge of anatomy and some good basic surgical skills.

At the end of the case, I needed a small drain. The bed of dissection was dry (all the apparent bleeding had stopped). But there is almost invariably a bit of ooze from something, and I really did want to put one in. It was a relatively big cavity and potential space. It would be much better to have a drain. Needless to say, no such item was present. Hmmm. What to do. On one of my earlier laparotomies, the team here had shown me how to make a corrugated drain out of a rubber tube by cutting holes in it. 

We struck on the genius idea of replicating this process, just with the thinner tube of an IV giving set. If you bend it over on itself and cut the corners, you can create fenestrations. With a bit of care (my OCD coming nicely into play here) the end result looks almost identical to a 6mm drain you would get at home. Great. Now for a bag. Initially we settled on using a sterile glove (this is their go-to bag for a lot of things like NG tubes) but when a bit of suction was thought about, we managed to attach it to a syringe. An absolutely fantastic result. Whilst such an arrangement appearing in a UK recovery would likely lead to a formal enquiry, here whilst it looked bizarre, it worked brilliantly. 

Enough for a badge perhaps?!