Well its been a pretty full on weekend. We were going to
head to Tanga for a day, but a mix up with the hospital cars meant a weekend at home. We
went roaming from the house on Saturday morning, having discovered that the
plot of land we look out over is actually part of the house plot! Further
exploration revealed a fabulous network of ‘shamba’ – small farms that most
people tend to own.
I popped into the hospital to check up on the patients from Friday.
I was relieved to find that they were both in very good shape and specifically
the hernia patient had suffered no apparent detriment from the mid-case
excitement. Unfortunately though, he had suffered a couple of quite substantial
bleeds from his wound, yesterday evening and this morning. When I first
attended him, he was lying in heavily blood soaked sheets with a dressing that
was soaked through. When I asked about this, I was informed that the dressing
had been changed several times?!?! Unfortunately, I (nor any other surgeon) was
alerted to this issue, nor was anything really done to address it! This is the
other end of the spectrum from the UK when the faintest hint of ‘ongoing haemorrhage’
would generate DEFCON5, requiring immediate attendance and review (I am being a
little flippant in this last statement). There was a mixture of relief and irritation
when I took down the dressings to find the culprit was a feisty vessel on the
skin edge (this is much better than something deep within the wound). I applied
pressure for 10min and it stopped. It is disappointing that Intensive Care
could not offer such intervention. Opportunities present themselves at the
strangest times and this seemed like an excellent moment to teach both the
nursing staff and the patient (plus relative) some simple first aid. I was very proud
of my Swahili, which far from fluent, clearly communicated what I intended it
to. When I returned later in the day, there had been no further trouble and the check blood
count was fine (although it had dropped).
The phone rang on Saturday evening whilst I was watching a
film with the chidlers (Laptops are great). I was relieved that it was not
about the patient on ITU. Instead there was a patient in bowel obstruction that
they wanted my review. It was almost 9pm. I quickly established that the patient
had been admitted to hospital on Thursday night but had only had an X-ray taken
today and had only had that reviewed this evening. The doctor I spoke to sounded
excellent, and I was rather relieved to hear that although the patient was very
distended, they were well and no especially concerning symptoms or signs. There
are almost no staff in the hospital at night. Only a handful of nurses to cover
the wards (less than one per ward), a midwife if required and a clinical officer.
If other staff are needed they are called in from home. Operations such as Caesarean
Sections do happen overnight, but the prospect of trying to arrange something
more complicated than this was massively concerning. We agreed a plan for the night
over the phone.
I reviewed the patient on Sunday morning with one of my other
surgical colleagues. The clinical picture was exactly as presented to me, and I was
actually incredibly impressed by the quality of the review that the patient had
received. It looked like the patient had large bowel obstruction, and the X-ray
strongly suggested a sigmoid volvulus to me (this is when a loop of the colon
twists around on itself, a bit like a sausage balloon, causing a blockage which
then gets worse until it explodes). Unfortunately, we had no equipment to try
and decompress the twist endoscopically (not even a rigid sigmoidoscope) so I was
left with a dilemma I would never face in the UK. Do I refer the patient to a
centre that might have endoscopy equipment (but would probably just operate on
the patient I am told, or possibly perforate the bowel if endoscopy was attempted)
or do we proceed with the only other option available to us, a laparotomy? In
no uncertain terms, I was told that a laparotomy here (done by me) would be by
far the safest option (whilst a huge amount of scepticism could be held for
this statement, it does correlate strongly with discussions I have had with a
number of other people). We decided to go to theatre. This would take some time to
organise (3hrs in the end). Interestingly, I was also told that such an undertaking would not
be safe at night. It was pushing it at the weekend, but several extra staff
came in for the excitement!. Those three hours gave me quite a lot of time to mull over the
predicament I found myself in. I rationalised, that whilst there were many
suboptimal aspects to this case, actually for him surgery was probably not a
bad option. However, I would be faced with a grossly distended colon and the
intra-operative options might be less favourable than if we had managed to
decompress the colon first. Furthermore, much of the kit that I would normally
use in the UK was just not available. But to make matters even more tricksy,
there comes the question of stomas.
Stomas are when the bowel is diverted onto the abdomen and
the effluent collected in a bag. The ‘simple’ default / safe position is to perform
a Hartmann’s operation, which involves chopping out the offending colon and
performing a colostomy. This in theory can be reversed at a later date, but reversal is by no means an easy option (and the usual timeframe would be 3-6months at
least, by which time I would be gone). Most likely it would be permanent. Furthermore,
there is no such thing as stoma care here. They do know what stomas are, but long-term
support for such an eventuality would be extremely limited. It would be the
patient, with his relatives, with limited stoma supplies and basically no back
up. I have no doubt that with the African resourcefulness they would find a way
to manage, but for me making the decisions today, that was a factor I could not
ignore.
As a colorectal specialist, presented with such a case in
the UK we would aspire to resect the colon, and join it back up. We would ‘protect’
this join with a different temporary stoma whilst it healed (a defunctioning
ileostomy with on table colon lavage). The trouble with this approach is that
there are also tests (not available here) that we perform before reversing the temporary stoma to
check that the colon join has healed. There are many more complexities to the
decisions required today that I could elaborate further, but perhaps one last fundamental one to mention is that you want an
alive patient at the end of your efforts.
It turns out we got the patient to theatre just in time. He
not only had a sigmoid volvulus, but he also had a closed loop large bowel obstruction
on the other side (the technical explanation for this is that he had a
competent ileocaecal valve). His caecum (first part of the colon) was about to
pop. If that had happened he would have died. Mortality from such an
eventuality in the UK is very high and that is with super high-tech Intensive
Care Units capable of supporting complex organ dysfunction. Here he would not
have stood a chance. As we opened his drum like abdomen, there was much delight
in theatre as the bowels bust out to greet us. Even more appreciation was shown
when a simple colotomy deflated them. As a colorectal surgeon, to have such appreciation
for what to me was my ‘bread and butter’ practice was a real joy. I was at home
in a case like this and although I was operating in a remote part of Africa,
with limited instruments, an inexperienced team and no personal professional back-up,
I was surprisingly relaxed. It was tiring though.
In the end, I did a resection and primary anastomosis of the
colon. I repaired the caecum and brought out a defunctioning loop ileostomy. It
all looked very nice in the end, but we will have to wait and see how he
recovers. I certainly did no gambling in this case, but there will always be
some calculation of perceived risks. I hope that his colon heals. Equally, I have
quite a lot of concern about how he will manage an ileostomy. But hopefully, I can
reverse this before I leave.
A quiet and relaxing weekend then….
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