My wife, chidlers and our visiting friends would be setting
off midmorning for a final weekend in Peponi, a last dip into paradise. The
plan was that I would join them later, but I had many a loose end to tie up
first. I had a lot to do today!
The whole day would be a very bizarre experience for me as
the realisation struck home that each activity of the day was to be my last
here. Sitting through the morning meeting, I made a special point of breathing
the whole experience in, trying to ensure I had some mental souvenirs to carry
away with me. I was sitting amongst my colleagues, many of them now friends, an
almost daily routine that was soon to end for me. The clinical officer report,
the nursing report then the death report (four this morning). There were the
usual discussions surrounding such things, notably for me was that the clinical
officer got a hard time for prescribing steroids to a snake bite (a quick check
of Dr Google confirmed that this is not ideal). Once again my educational hat
was immediately wondering whether this important discussion would be disseminated.
Would there be learning and change? Would my consistent contribution to
encourage such things begin to reap rewards? This morning it felt unlikely for this particular case, but
seeds have been sewn and perhaps they just need time to germinate. The meeting closed
with a reminder by the hospital superintendent of my departure. The reaction
was generous; nobody wanted me to go but of course everyone wished us well!
I had an agenda today and for once I was assertive in
dictating it. I needed to be super-efficient with my time to get everything
done and get away at a reasonable time. There was one final operation to do, I
needed to pack, and I was desperate to finish my present for the team.
I explained my time pressure to the local surgeons and we
agreed that they would call me when the patient was ready in theatre. It was
then back to the house to get on with my other tasks.
Firstly, I gave my attention to the present I was making, a
photo-board (mugshots of the team) for the department. A familiar site on most
NHS walls, I felt it would be both nice and valuable here. It had taken a long
time to get done and I had been working on it in one way or another since
before Christmas. However, as often seems to happen when an absolute deadline
looms, a flourish of activity can bring it all together. My friends had been
amazing in printing out quality photographs for me in the UK (I had struggled
to easily find anywhere to do this locally), and my wife had managed to find a
good quality pin board in Tanga yesterday (blimey, I completely forgot to
mention in yesterday’s post that she had to go for round three of our visa saga
– success I am delighted to report). But I got it finished just as the team
called me to theatres.
Whilst Fridays are usually reserved for
emergencies, we had been given the go ahead to do one of the two skin grafts still outstanding. Hoping to get them both done this week, for various reasons we had managed neither. Although disappointing, it was great that we would at least get one done.
There were three patients on the ward who had been admitted
over a month ago with horrendous leg ulcers. All young men (one in his 20s, one
30s, one 40s), two had sustained traumatic injuries and in the other they had
emerged spontaneously (some infective cause I suspect). All three were
substantial, encompassing most of the gaiter area (calf / ankle). Presenting
late, all the wounds were infected had required extensive debridement, surgical
toilet and dressings to try and salvage the legs. With such nasty wounds and extensive
skin loss, these three men were flirting with the need for lifechanging amputation. However,
some excellent basic work in both theatres and on the wards had gone a long way
to salvage the situation. Two were now suitable to attempt grafting.
I had been really keen to get this done before I left as I
had brought out a very heavy but brilliant bit of kit with me. If I could get
the local team trained up in its correct use, it could transform their ability
to manage these wounds. To put it bluntly, it might make life changing
amputations unnecessary.
 |
| The Brennen Mesher |
A Brennen Mesher took up a massive 6kg of our baggage allowance,
but it is a beautifully machined tool that dramatically improves both the
success of and scope of skin grafting. After taking a donor of skin (usually
from the thigh with a special knife), you run it through the device and it
creates fenestrations. This does two things, firstly it allows fluid out from
underneath the graft when you lay it (blood, exudate, bugs) and fluid under the
graft can prevent it from healing (it needs direct contact with tissue to get
the nutrients it needs and to grow the tiny blood vessels that will allow it to
live). Secondly these fenestrations allow it to cover a much wider area. The
one I had brought out doubles the size of the graft.
With the patient on the table, I took down his dressings.
The wounds were granulating well (this means trying to heal, creating a bed of
tissue that the graft can sit on and grow onto). But there was a slight
suggestion of low grade infection. This is not ideal as it reduces the chances
of it healing, or ‘taking’ as we tend to say. Simply put, infection can kill
the fragile graft. But it was now or not at all and I felt it was worth a try.
This is not an easy decision as if the graft fails, you have created another
ulcer on the thigh for no benefit. And these donor sites are not without
potential complication, and they do scar. For a grafting of this size the donor
site would be large.
I have done several skin grafts in my time, but on a smaller
scale and I had not used the Brennen Mesher before (I had used other systems that require expensive disposables). However, the instructions
that I had received before leaving the UK (and my experiments with paper) meant
things went very well. My only quibble with myself was that the donor harvests
with the Humby Knife were a bit ragged. You have to use this special guarded blade to regulate
the thickness of the slices you take – too thin and the graft falls apart, too
thick and the wound you create doesn’t heal - the donor site relies on the
skin regenerating from the skin follicles that lie deeper than the slice taken.
My comment about this ‘unsightly’ work was met with a wry
smile and utter bemusement. If not for my self-appraisal, neither the patients
nor the staff would have even registered that there might be a cosmetic
consideration. However, my professional pride was a little dissatisfied, which
I think is important. I mention this because I believe it is the expectations
that I have of myself that has driven me to strive for UK standards whilst working here. By doing
this, remarkably perhaps, we have managed to achieve surprisingly good outcomes on the
whole during my time here.
Nevertheless, the skin grafts were laid upon the gaiter wound, looked very
satisfactory and were dressed. I can now only cross my fingers that they will take.
They will remain untouched for 7 days before they are inspected. Too soon and
you risk peeling the graft off with the dressing and ruining it. He will be on
bed rest and antibiotics.
I will of course, be back in the UK for the moment of
reckoning. Far from ideal but I have confidence in the team. There is also a distinct deja-vu about this situation. During my brief previous visit in July, we did a smaller skin grafting
on a foot on my last day. That time the take was 90%. If we can get anything
close to that it would be amazing and limb saving for this man.
And that was it. My last operation in Muheza. I walked away
from the operating room with a jovial exterior but a heavy heart. I was very
sad to be leaving. All that was left to do was to present them with the gift
I had made and say my final goodbyes. I don’t think my departure had really
sunk in for any of us.
I left behind my scrubs, theatre shoes, headlight and a few
other bits. But most of all, I hope I have left behind a legacy that will enable
this surgical department to continue to grow. Turning away and walking out of
the hospital gates was really hard. In my heart, I know that there is more
unfinished business here than just the skin grafts and I hope that it will not
be long before I can return, if even for just a short time.
I walked home and packed. At 3pm I climbed into the Hospital
Car and drove down the dusty, bumpy road away from the hospital then out of
town for the very last time. I had one last night in Peponi and would be
leaving at the crack of dawn tomorrow to fly home.
 |
| A final photo, the two local surgeons and myself |
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