Hitting the wall

For some reason today I have felt incredibly weary. Perhaps it is the stifling heat. Perhaps I am a little under the weather (two of the childers have had ‘head colds’ and I’m a bit snuffly) although I felt great on my run this morning. Or perhaps I am just fatigued by what we are doing here – have I finally ‘hit the wall’ of this ‘endurance event’? Regardless, it is draining, not least because by being aware of such things you work especially hard to ‘keep going’ and ‘put on a brave face’. Which of course is all the more tiring. 

Theatres seemed to be on a go slow today and we only managed to get three of the four cases done that we had intended to. It was originally only going to be three planned cases, but an emergency needed doing (strangulated hernia) and it seemed very realistic to fit this in as well. Evidently not. I waited patiently as the clock ticked by and whilst I drank some tea and caught up with some admin, I also listened to the somewhat concerning noises that accompanied the installation of a white board that I had bought for the department. What I thought was a fairly simple job requiring a drill and a couple of screws, the approach employed seemed to include quite a lot of loud hitting of the wall – I could feel the vibrations of each blow where I was sitting. Quite alarming. The analogy involving a sledgehammer and a nut came to mind... It is up though and seems to be fairly secure. The wall also looks to have survived. 

We did not start our first case until 10am, a 4 ½ year old child with what was either a lipoma (fatty lump) of his lateral abdominal wall or an unusual hernia. I have become so sceptical about the quality of our ultrasound imaging here that surgical exploration was the only way forward. I dutifully waited until he had been intubated before scrubbing (ready to provide back up if required) but all went smoothly and so off I went. However, on my return to the room (the scrub sinks are outside) somehow the ET tube (breathing tube) had come out (a medical student told me it had fallen out whilst other things were being done) and I saw the disastrous scenarios of the past flashing before my eyes. Not again?! Fortunately, a little calm authoritative support / direction was all that was required and the situation was promptly resolved. Not wanting to be blazé about his worrying desaturation, it was not for long and I’m sure he will be ok. The surgery went well, although it was bit of a fiddle as I was trying to keep his incision (scar) as small as possible and the lipoma (as it turned out to be) was extensive.

I had wanted to let the two local surgeons ‘sweat’ their way through the emergency case together. I say ‘sweat’ metaphorically because the A/C in theatre was working very well today. However, I wanted to give them an opportunity to work together as a team and get through this difficult case without me. It proved to be a step too far. In fairness to them, until the specialist surgeon returns from training in November, they would refer such a case on to the regional hospital. They managed the approach, but the hernia itself was troublesome and on reducing the scrotal contents into the wound the extent of the trouble became apparent. This was a genuine strangulated hernia and part of the wall of the caecum (first part of the colon) had infarcted (died) and was starting to perforate. I quickly deployed some damage limitation measures and got control of the situation. I managed to perform a wedge resection of the caecum which ended up looking very pleasing. Let’s hope it heals. In this context, repairing the hernia with mesh felt unwise. We thus performed a suture repair which I hope will be sufficient. Interestingly, the scarring that often accompanies a low grade infection (inevitable with such a case) will often result in a very sound long term repair. 

With all of that, we had to cancel the next elective hernia, but we agreed that the planned re-look of the scrotal abscess should be done. This was very pleasing and we were able to close most of it today. 

It was quite a relief to finish for the day and get home. Fortunately the power is on and the fans take the edge off the heat. The Chidlers are all on good form and really enjoying our new batch of elective UK medical students. Hopefully a good night's sleep will revive me, and tomorrow I can once again step up to the challenges of the day with a relaxed smile on my face.