Take three; the downs, the ups and small victories.

The lady from yesterday died this morning.

I found her in ‘ITU’ this morning still intubated and still on the theatre anaesthetic monitor. On the one (positive) hand, this is perhaps a glimpse of what the ITU ward could become here, if only it had some equipment (as previously described the ITU is nothing more than a 4 bedded ward with one dedicated nurse [usually present], a pulse oximeter and access to a couple of oxygen concentrators). On the other, it is always a bad sign when someone tolerates a tube in their windpipe without additional sedation. Whilst she was still breathing when we went round, she died shortly after this. Her family made the customary announcement with crying, wailing and shrieks of grief. Whilst completely understandable, the sounds of this cathartic process drifting over to where I was sitting in theatres waiting to do the next case of the day certainly didn’t help the way I was feeling about it all. But this is medicine. And we deal with it.

Victories come in many guises and I will embrace and enjoy any that come my way! Remarkably, a replacement element for the mesh autoclave was found in Tanga yesterday. It turns out that the Indian made autoclave, uses an Indian heating element common to several other products (for example a certain kettle I understand). I installed it and am delighted to report that it works! We are back in business again; mesh surgery is a go!

Out with the old, in with the new!

This meant that we were able to tackle the waiting hernias. The first of these was a whopper, a monster. His right hemi-scrotum reached almost to his knees when standing and was the size of a prize marrow. This was always going to be technically challenging, but it turned into quite a marathon, not least because of the unexpected ‘excitement’ midway through the case. I don’t think the team this week got the memo telling them that I am a surgeon and not an anaesthetist. Hmmm. All started well with the patient given a slick spinal (the local practice for hernia surgery) and we began our dissection. It was difficult, but we made steady progress defining the anatomy and the gaping defect in the lower abdominal wall. We eventually managed to deliver the hernial contents from the scrotum into the groin to allow us to work out how to return them to the abdomen. The problem was that it was a bit of a mess. The trouble with such chronic hernias, is that huge amounts of scar tissue forms, which makes defining and protecting crucial structures like bowel and the blood supply to the testis very difficult. You can’t just push it back and patch it over and hope for the best. This dissection is time consuming at the best of times, but today it was even more so. Inevitably this meant that the spinal started to wear off.

We surgeons were engrossed in our work when a lot of kafuffle began to happen at the head end. It was properly scary, I thought the patient was about to die on the operating table. What I know now is that whilst we were working, the anaesthetist converted the anaesthetic to a ketamine GA (this means that the patient gets a hefty dose of ‘Special K’ and allowed to sleep whilst oxygen is wafted over their face). Usually, this works surprisingly well and surprisingly safely. Unfortunately today however, this patient had asthma and I am guessing went into bronchospasm (this means he closed off his own airway, suffocating himself) because some increasingly animated efforts of airway control and bag ventilation were followed by chest compressions. I downed surgical tools, guts all over the groin (my colleague hastily sensibly covered these all up I noticed – situational awareness?!) and rallied to the cause at the head end. We quickly got the patient back to a place of safety and after trying a few things that I was not happy with, for the second time in two days I intubated.

I would be lying if I wasn’t just a little bit shaky as I then rescrubbed 30 minutes later to continue the operation. We finally made sense of the sac and its contents (complex adhesions involving caecum, appendix and small bowel) dissected it clear of the spermatic cord (lifeline to the testis), reduced it and began the process of reconstruction. To add to the fun and games, because the blood pressure was low (probably related to the original spinal anaesthetic) the drugs we were now using had to be run at a very low rate. This meant that sporadically he all but woke up, coughing or straining, expelling his abdominal contents back into his groin as we were trying to reconstruct it. Far from ideal. Nevertheless, we got things done and patched up, almost looking normal (although straining at the seams a bit).

Now a decision had to be made about the fate of the testis, the mesh and the scrotum. We were under the cosh, in the heat of battle so to speak, and I was very worried about the length of time he was ‘asleep’ for. Every minute counted. For the testis, the pressing question was should it stay or should it go? My Tanzanian colleagues encouraged me to take it, and in this case; it went (which was heart breaking for me in some ways having managed to define the structures so well up to this point). However, the hernia repair would be considerably stronger without having to worry about the cord and there was a lot more dissection that would be required to debulk the remainder of the heavily scarred scrotal contents (these were also now in the groin). With a healthy contralateral testis, I still think in the circumstances it was the right thing to do. The mesh went in, sitting very nicely and the end result was good. We ‘gilded the lily’ with my first ever scrotoplasty which went surprisingly well too. I have some fantastic before and after photos (taken with consent), but can’t possibly post ‘willy pictures’ on a blog like this!

Exhausting. And just an exploratory laparotomy to do before home…..