Trauma

Mango Trees, it seems, are dangerous.

We were making our rounds when the first victim of the vicious mango tree presented. He had just been brought up the very bumpy road to the hospital in the back of a pick-up truck. He was then ‘transferred’ onto a hospital trolley, each of his four limbs held by a companion (friends or perhaps family members) as he was lifted, swung over and plonked onto the very hard and narrow gurney. During this process some sort of triage had taken place and he was then wheeled up the main hospital corridor and brought straight to the surgical ward. He was in his 30s. He had fallen from a significant height out of a mango tree. He couldn’t move his legs. He had no feeling below the waist either. Remarkably, after a rapid assessment, he otherwise appeared ok (although there was a possible history of him losing consciousness). Now anyone medical will be reading such an account in horror. What no triple immobilisation? No log roll? No spinal transfer? No rapid assessment in an emergency resuscitation room? No ATLS?

A typical mattress. Hard to keep clean 

and certainly not pressure relieving

Nope. None of that. This sort of case, transport to hospital, assessment and management is pretty standard here (earlier in the week I spotted a lady sporting a crutch in hand, pass through the hospital gates on the back of a bodaboda (motorbike), obviously no helmet). There are definitely Darwinian principles at play in the face of such limited healthcare resources. But, part of my presence here is to try and be a role-model so we made a comprehensive and rapid assessment of the patient. Apart from a few minor cuts and bruises, it seemed to be an isolated spinal injury (this is in itself devastating). Having seen at least a handful of patients like this since my arrival in November, I knew that he would likely get 6-12weeks of bed rest with very basic, if any nursing, his basic needs probably being left to the family visits to the ward each day. The concept of regular turning to prevent pressure sores does not exist here, not least because there is just not the number of staff to make it possible. And of course, the mattresses are far from pressure relieving. So it would then be a case that he would either recover… or not (more likely) and then eventually return home entirely dependent upon his extended family. I am yet to establish if there are any specialist centres for such injuries, but I was quite clear he needed escalation up the ‘food chain’ and so suggested immediate transfer to Bombo regional hospital in Tanga. We did no tests (bloods or X-rays) as these could not go with the patient and would incur additional costs he could not afford. For patients such as this they are taken in the hospital car (the back of a 4x4, on a hard stretcher, with no escort) but I believe this service is at least free.

The remainder of the day was very pleasant, with just one hydrocelectomy beautifully carried out by the more junior local surgeon under my guidance. It was then home for lunch and some time to tackle the mounting list of clerical tasks I face. The only trouble with being proactive and undertaking such activities as visiting Bombo, is that it fuels my ‘blue-sky thinking’ and enthusiasm to do more. I now find myself trying to establish and nurture ‘new’ networks and links for the hospital (and potentially further afield), hopefully boosting collaboration and thus the provision and development of services. There are many inspiring local people in Tanzania and I think that with the right help and support healthcare could rapidly improve.

Resourcefulness. 

A novel way to spigot an NGT

At 5pm, I popped back into the hospital to see my laparotomy patients. I would be leaving early in the morning for the capital Dodoma and away for three days. I wanted to ensure they were progressing well. Indeed, they are. One is going home, the other (gastric perforation) is settling well. I have removed his NG tube (stomach draining tube) and am allowing him to eat tomorrow.

As I was walking into the hospital however, my phone rang and I was told about the second mango tree victim. This time an 11 year old boy. He too had fallen from a height and broken his arm, but the staff were very worried about his abdomen. I found him on the paediatric ward in the small treatment room with his arm in plaster. I entered the room through a large ‘honour guard’ of his extended family, no doctor in sight. There was however at least one nurse present (but this may have been a student). He was cold and thirsty. His repeated quiet but clear calls for ‘maji’ [water] told me much. His body was trying to do everything it could to correct his blood loss. He did not look great. He complained of abdominal pain. He had no observations recorded, had no IV access or fluids running but I was told that bloods had been ordered and an USS report was thrust into my hands. For what it was worth (I have become increasingly sceptical about the service here), this suggested free fluid (blood) in the abdomen. I was also told that needle aspiration had drawn fresh blood. I made a rapid but thorough assessment. Interestingly, the signs in his abdomen were not nearly as dramatic as I expected. I then established that he had also lost consciousness for 5 minutes when he had fallen. Hmmm. To me he was clearly shocked (meaning he had lost a lot of blood). In trauma circles there is the adage ‘on the floor and four more’ when considering the source of blood loss. It is important not to overlook any of these potential sources. He had no external haemorrhage, his thorax seemed blameless, he had no pelvic pain or tenderness, his long bones (thighs and upper arms) were fine. Everything pointed towards his abdomen. He needed resuscitation and surgery. Now. My strong suspicion was he was bleeding heavily within his abdomen. We needed to address this urgently and ‘turn off the tap’. A cannula was sited. Fluids were being set up. There then ensued a bit of faff as, after the shortage yesterday, we needed to determine whether we had enough anaesthetic drugs to actually safely perform his surgery. Thankfully, we did.

It was a relief for me to see him in theatre, on a monitor, with IV access, fluids running and blood for transfusion arrived. He was anaesthetised without mishap and we opened his abdomen. Blood. And lots of it. No faffing. Bigger incision. Pack. Pack. Pack. Pack. Four quadrants. The principle of this is that you can hopefully get control. Things happen rapidly but I made two very quick mental ‘thank you’s. One was for our newly developed abdominal packs (whilst still on the small side, they meant we could actually stop the bleeding, without them I think he would have died). Secondly, I was also grateful for my comprehensive surgical training in the UK. Whilst I have nothing like the trauma experience of military surgeons or those from SA or the US, I have been in such situations before (although not in a child) and my instincts just kicked in. This too probably saved his life. I do not think he would have survived transfer. He had bled a lot.

We achieved stability and I started the process of trying to identify and rectify the cause of bleeding. Fortunately we had the Poole Sucker I had brought with me from the UK (a metal tube that makes it possible to suction fluids effectively from the abdomen). We carefully removed the packs sequentially, removing the copious blood, looking for injury and active haemorrhage. Firstly the pelvis, no bleeding left, no bleeding right…. But a glimpse of a retroperitoneal haematoma in the midline. Gulp. This could be very bad. This is the location of the main blood vessel of the body. He was still stable. His heart rate falling with the blood and fluid we were giving him (good sign). The haematoma was not evidently expanding. Move on. Blood in the left upper quadrant. I expected this. Hand in, spleen scooped. Several tears in it. But it did not look awful. I hesitated. In the UK we might have been able to consider splenic conservation, but here…. No monitoring, no CT, no interventional radiology. So many good reasons not to leave it. Out it came. No question. A very straight forward splenectomy. The rest of the packs came out. We were stable. Wash, wash, wash. No obvious ongoing haemorrhage. Great. Final inspection before closing. I breathed a big sigh of relief. It had gone so well, I was not even going to need to leave a drain in. A close look at the retroperitoneum was also somewhat reassuring. Whilst bruised, there was no expanding haematoma. Leave it. Further exploration was much more likely to cause harm.

Last look before closing. Lower abdomen; fine. Left upper quadrant; splenic bed dry. Great result. Right upper quadrant, small clot above the liver – I assumed this was old blood that had settled there. I retrieved it carefully, but my fingers brushed something they knew wasn’t right. Gulp. Adjust the light. Better look. There was some fresh blood now. This is bad. Very, very bad. What liver I could physically see looked ok, but I knew something was not. Very not ok. I carefully slid my hand up over the soft slippery surface of this 11 year old boys liver. It should feel smooth. Slowly, gently. And they reached what I had found before. The tips of my fingers could feel a rent in the top of the liver. Right at the top. I carefully, ever so carefully, made a mental map from what my fingers were feeling. It was quite a size, perhaps 5cm long. There was no mistaking the transition from healthy capsule to squidgy mushiness. Gulp. I was reluctant to somewhat blindly pack up above the liver now, fearing we could make things much worse (it would be very easy for the placement of the packs to further tear the liver tissue). I repacked the abdomen, putting surrogate pressure on the area, hopefully apposing the torn edges to promote clot formation, and waited. If it did not stop, I would be forced to pack above it and face making things worse. If that happened, the only way to save his life would be to mobilise the liver. The prospect frankly terrified me. I could confidently do a Pringle Manoeuvre (a means to reduce the blood supply to the liver), I vaguely knew the principles of mobilisation and I have always been interested in anatomy, but not being a liver surgeon to have to consider such a thing is troubling to say the least. I literally saw his life potentially slipping though my fingers.

Ok, deep breath. Packs out. Gentle, ever so gentle look. No torrential haemorrhage. Some relief. Wash. No doubt some new fresh blood, but I could see it was clotting. Second gentle rinse. Seemingly ok. Tentatively ok. More decisions. I am sure in the UK, I would have packed his abdomen, temporarily closed it and transferred him intubated and ventilated onto ITU. Well actually, if I was personally involved with such things, it would be in a District General Hospital and he would be transferred in a very special ambulance to a big Teaching Hospital with a specialist Paediatric Intensive Care Unit and specialist paediatric and liver surgeons. None of that here. Not even the option to keep him asleep and intubated and ventilated for a relook at 24 or 48hrs. A horrible mental debate took place in my head. To pack or not to pack? My hesitation to pack was because of the possibility that it could make things worse. Also, he would be awake with packs in his abdomen, which would be uncomfortable to say the least. Furthermore, I was being told that he would need to be transferred to Bombo for further blood and blood products. If he was packed, it would mean that a relook laparotomy would have to be carried out there. A careless hand at such surgery (which is easy to do when you are not present for the first operation) could tip the balance catastrophically for him. I am not one to gamble, but this time it felt a little bit like any decision I made would be spinning the roulette wheel for him. I decided not to pack. I put some drains in, one alongside the liver, one to the pelvis. One final look before the final pass of the closure needle. Apparently dry. Closed. I crossed my toes as we completed the skin closure. I had done everything I possibly could have here. But it felt short of what I would have like to have done. I didn’t even have any surgicel (a clot promoting cloth you can lay over things such as the liver). It was up to him now and another seemingly casual role of the dice of Fate that led to his current predicament. Not least living in a resource limited place such as this.

Our lead anaesthetist wanted to escort the patient to Bombo which was fantastic news as far as I was concerned. I phoned the head of surgery, something I wouldn’t have been able to do before my visit on Friday, and handed the patient over. Offering the boy the best possible ongoing care. It was also nice to talk and continue to develop this link. He was very understanding and happy to receive the patient. I was beginning to feel happier about the situation, not least as I was due to catch the bus first thing. Before I hung up, he mentioned the patient from the day before. She had had her surgery performed this afternoon – so much for transfer for urgent laparotomy yesterday. There was gangrenous bowel (no doubt about it 24hrs later) and a bowel resection had been performed. She was doing well. Great. Although a mixture of pleasure that she was well and irritation that she had not had surgery yesterday. Hmmm.

I was home late, almost 9pm. I missed our farewell supper with the lovely Australian medical students (mine was in the oven), but did catch them as they walked out of the door. It was nice to say goodbye, they have been great.

I am due to go to Dodoma tomorrow, the new capital of Tanzania, to visit the Specialist Surgeon in training who will return to Muheza to take up a role as head of surgery here in December.

Cross your fingers and toes for the young lad. He has a lot of healing to do.