Dilemmas

I think I can confidently say now that this trip has presented me with more very difficult professional dilemmas than I have faced in most of the rest of my career. And they find you at the most unlikely times….

Today has been a very productive day in theatre, with two more hernia repairs completed with mesh. Most pleasingly, the second of these was performed by the two local surgeons together (albeit with me scrubbed and providing quite a lot of hands on direction). One of them had even come in during his holiday “kuendelea na kujifunza kwake” (to continue his learning!) It is such a privilege to ‘watch’ as a project begins to unfold in this way. For all the hard work, it is immensely satisfying. We may still have a long way to go yet, but we are making great progress.

Another little moment of pleasure came when we walked into theatre this morning. Not only is it midway through an overhaul-come-deep-clean (thank you team Hereford), as I glanced at the newly marked up whiteboard I noticed some carefully entered data. On closer inspection, I realised that this was not from a case of mine. Rather it transpired that it was the checks and counts related to an emergency caesarean section performed in the early hours of the morning. Wow! Fantastic! Even at that unearthly hour, the team had not only thought about doing it, but had also actually done it. That is excellent. We only really introduced this process last week and already it is becoming habit! A shifting culture and an important step forward. And to be honest, really very pleasing.

…so dilemmas. I had earlier in the day been shown the foot of a six year boy who had a massive growth on it. The likes of which I have never seen before. I assessed it carefully and suggested that we get an x-ray and tee up referral to a specialist orthopaedic centre. I was clear that this was not something for me to tackle. However, my intrigued surgical mind was contemplating what it might be and how it might be treated. Fundamentally, is it a benign growth or malignant (cancer)? And could it be excised preserving enough skin to close the wound, or would some complicated flap be required to reconstruct the foot (I have become much more aware of, and impressed by, such things, having seen the work of the plastic surgeons in Salisbury)? It would be essential to preserve the function of the foot, assuming the lesion could be safely excised. All academic thinking though as not something for me to take on….

Photographed and posted with consent

….or might I need to rethink that position statement? Having finished theatre for the day, I was bowled a complete googly. The local Surgeon informed me that the family were quite clear that they did not have the money to travel to a specialist centre, nor the money to pay for the treatment there. They were desperate to have something done, but their only option was to have something done here. It was treatment here or not at all. The ‘not at all’ option would be a very bad one for this child.  I can’t quite capture the multitude of thoughts that cascaded through my mind at that moment. They started off with something like ‘no way, I’m not doing it’, but as my mind raced other things popped into the mix; ‘I wonder if I could do it’, ‘I probably could do it technically’, ‘however it would not be the right thing for me to do it’, ‘whatever you do, don’t make things worse’, ‘but what other option does he have?’ My mind was full of doubt and questions. Not least because without further investigations (unavailable to us here), it was really glorified guesswork to decide whether it was cancer or not. On the balance of things, probably not, but I caught myself thinking that I would never settle for such a position back in the UK. But then this child would never be in this position back in the UK. So, what to do? How to make a decision like this? All the options are definitely sub-optimal. And I have only captured a fraction of my thinking in this paragraph.

Time is a great thing. There is of course, no rush to operate today, or even this week. There is a lot for me to consider and I will seek some advice from friends and colleagues afar. This child is in a bad position. Quite possibly a relatively simple operation (or so I am telling myself) could be life changing for him. But I would never want to gamble with such things and so if I am to do anything, it will be as preparedly as possible. Even if we may have to accept the suboptimal, it will be a thoroughly thought through and meticulously prepared sub-optimal. It is a balance of knowing what I can do, knowing what I should do and trying to know what is the right thing to do. All of which may be different. Difficult. Very, very difficult.