The blood brain barrier

I continue to be impressed by the commitment and innovation that I find here in Tanzania. Perhaps, it should come as no surprise to me that such traits would flourish. But it certainly brightens up my day when I see another small step moving things forward. Today it came from a trainee Nurse Anaesthetist. She is away studying this year at the Zonal Hospital in Moshi, but is currently on her 4-week block of holiday. So, of course, she comes in every day of her holiday to work for free in the hospital ‘to gain a little bit more experience’. She is very good and works very hard.

The 'blood brain barrier' seen at the top of the photo.

Today I noticed that the ‘blood brain barrier’ had been erected. This is the affectionate term used by theatre teams to describe when part of the surgical drape is used to shield the head end of the patient from the surgical site and vice versa. Blood being the realm of the surgeon, brains to describe the anaesthetist (I think we can guess who coined that phrase!). I had not seen it used here…. and I am not too sure why I hadn’t asked for it (perhaps trying to explain such a concept was too daunting as being scrubbed I would desterilise myself if I tried to erect it). Nevertheless, I was delighted when it was put up today. It was immediately apparent how greatly it improves the quality of the sterile field here (the drapes are quite small and basic). For the hernias it will add another layer of cleanliness to the cases (less likely for the patient to cough over the mesh or an accidental stray hand desterilising the field unnoticed). It is also low enough, I am pleased to report, that I can still clearly see and communicate with the head end (the importance of this will be evident from previous posts).

Perhaps a small thing, certainly something I would take for granted at home, but it is just another example of how things in Tanzania are moving forward fuelled from within the country. Experience being shared and disseminated. It is great to see and be part of, and again adds to my belief that all the time and effort we are investing here is both worthwhile and sustainable.

Unfortunately, the case itself was less pleasing. I had anticipated it would be challenging (I refused to start it before the blood crisis had resolved – temporary fix now in place), but was hopeful we could achieve a good result. She was a lady in her 40s who I had been asked to take to theatre before Christmas for appendicectomy – the ultrasound scan report had strongly suggested such a course of action. But when I saw her, she clearly had a mass and of the like which I could easily make things considerably worse by rushing in to surgery. I cautioned patience (to the disappointment of the local surgeon, I had to explain that a good surgeon knows when not to operate) and we treated her for two weeks with IV antibiotics. She improved and was discharged. I committed to surgery on a semi-elective basis if things did not completely settle down. To my mind, she either had an appendix abscess or a perforated cancer. I remind you that CT is not an easy option (patients have to travel a very long way and is prohibitively expensive).

Intraoperatively, I found myself looking into an abdomen I would never have entered in the UK. A CT would have told all. As she was put to sleep, I had increasing concerns (an anesthetised patient is relaxed and subtleties in the abdomen can become more apparent). Her entire right flank was rigid and the mass felt more extensive and very fixed. Hmmm. We opened. Sadly, the intra-abdominal compartment was pretty blameless, but there was an extensive mass palpable in the right retroperitoneum. It is either a posteriorly perforated and extensively locally advanced colorectal cancer, or a tumour arising in the retroperitoneum (like a big renal tumour). There was nothing I could do. We closed. It is always disappointing when you commit so personally to try and help someone, to be faced with something beyond such measures. I will see if she can travel for a CT to at least help inform her prognosis. But realistically, the sort of chemo-radiotherapy that we can offer in the UK is not available here and so, in some ways, a scan could be viewed as an expensive academic exercise. Hmmm. Very sad. I did not become a cancer surgeon to be faced with such situations. We do get late presentations of cancer in the UK, but we are able to perform extensive diagnostic tests (down to millimetres of tissue planes on special scans) that gives us a much clearer idea of what is and isn’t possible. Whilst the boundaries of cancer care are being pushed all the time in the West, I’m pretty certain this would be beyond even anything we could offer there. However, more information would allow an informed discussion with the patient, and palliative (life prolonging) treatments would be available to try. Here none of that is available and it often feels like guesswork (or is that clinical acumen).

The X-ray machine in pieces. It's looking terminal.

A final blow for the day is that the X-ray machine seems to have given up. It has been coughing and wheezing for about two months now, but I understand that last week it had ‘retired hurt’. It has seemed fragile ever since my arrival here last November, but every time I enquired about its health I had been told that it was all to do with power outings and taking a long time to warm back up. Hmmm. Its persistent illness resulted in a visit from the national technicians yesterday. It seems that unfortunately, the retirement may be a more permanent one. Everything that could be tested has been and is fine, but it still doesn’t work. Hmmm. This is a massive blow. Massive. For the patients and the hospital. I am not sure how a replacement can be organised, but I fear that even if possible, it will take months.

Just as progress seems to be gaining momentum, an important string to the bow snaps. Can a hospital function effectively without an X-Ray machine? We will find out I guess.