Irritation, disappointment and selfish relief.

Another new week and whilst on the one hand I was ready to start afresh this morning after the lovely weekend, I was still feeling a bit drained from last week and had so much still to catch up on. I was thus somewhat deflated, within the first five minutes of the morning meeting, by the news that there was a new patient with bowel obstruction that required my review. Only five minutes into the new working week and the day was already looking complicated, requiring a juggling act between the wards, theatres and outpatients. Far from ideal.

However, there is no room to be crestfallen or grumpy in Africa. Everyone is so smiley, lovely and appreciative of your presence that it is extremely difficult not to be carried along (and lifted) by such an environment. The wealth of increasingly familiar colleagues beaming at me, greeting me and asking after my well being and that of the family quickly gets you back on track. And that was just in the short 25m or so walk to the main corridor!

Rounding the wards brought further good news with the two laparotomy patients recovering very well indeed. I reviewed the new patient and they did indeed need emergency surgery. So, division of labour was required. Unfortunately, the immediate ‘fly in the ointment’ was that the local lead surgeon was tied up all week with examinations of the Medical Students. Hmmmm. Well we would just have to manage and hope that the outpatients would be gentle. I went to theatre to organise the case and then decided that a cup of tea was needed before clinic. My go to Pep-up-potion. I also wanted to prepare a piece of mesh as the emergency patient had an incisional hernia that would benefit from its use, providing the mischief in the abdomen allowed it (overt infection is a strong contraindication for its use).

Clinic was definitely lighter than usual (possibly because word had gotten around that operations would be limited this week as I would be away from Wednesday (more about that in due course). However, it was not long before we were visited in our clinic room by the lead nurse anaesthetist. I was told that we were very low on Ketamine (only two vials available) and that we were unable to get more stock today. This was extremely surprising to me as it is such a commonly used drug in Africa. But, I had seen the lengths the staff have gone to in the past to keep our activity going and so I just had to accept such news. Furthermore, they reported that proactive enquires about acquiring other induction agents (like propofol) had faltered too. With such limited supplies we could not risk starting such a case. This meant the only safe option available was to transfer the patient to Bombo regional hospital. I would be lying if I wasn’t irritated by such a notion, partly because I felt her surgery would be better performed here (not least if mesh would be suitable). There was also an element of professional pride being slightly dented by having to ‘accept defeat’ in the face of a department I had only just visited! But we had to do the safe thing for the patient and safe anaesthesia is crucial and she needed surgery today. However, I would also be lying to deny that a tiny part of me breathed a sigh of relief at having my day significantly simplified. Perhaps I would now finally catch up on my clerical work.

As the clinic came to a close, an unexpected pleasant surprise awaited in the attendance of a patient I had seen during my visit in July. At that time, he had had a large chronic ulcer on the top of his foot following a motorbike accident. It had been raw for over 2 years with the tendons evident below a thin layer of granulation tissue (the bodies attempt at healing). These wounds are notoriously difficult to manage (often requiring complex flaps in the UK), but we had performed a skin graft (transposing a superficial graft of skin from his thigh onto the wound). Sadly, I had not been able to see the result of our efforts in July as the wound needed to stay covered for 7 days. By that time, I had been back in the UK for several days. Whilst I did get sent a photo by WhatsApp (the wonders of technology), which looked encouraging, it was lovely to see the result in person for myself today. Even though the reason for his attendance was that there was a small area of the grafted wound that had not taken, 80-90% of it had. Given the troubles that these wounds often cause, not least in a dusty, hot impoverished country like Tanzania, I was delighted. We discussed the wound and the options now available. I reassured him that it would likely now heal given enough time, but he was keen for more surgery. Possibly influenced by a healthy dose of flattery, I agreed to re-graft the remaining area which we will do next week I hope.

Donor site on the thigh