We returned from our R&R on Monday just as the Prof was off to Lusaka for a whistlestop trip home. This time Sidney, the excellent Zambian trainee, was also here so we ran the show together. There really wasn't too much major going on, but a few big emergencies came in which we dealt with.
First up was an elderly man with a gangrenous leg which I amputated. This is actually now feeling rather old hat (we do a lot of amputations) so was by far the least challenging of the emergencies.
Then, while Sidney operated on a huge (at least watermelon sized, but above knee on the African "above knee/below knee" scale) incarcerated hernia I did a laparotomy. This seems to be sigmoid volvulus season (a volvulus is where bowel twists on its blood supply and becomes blocked then dies) and we have seen several this week. The trick is to operate before the bowel dies and resect the offending bit of colon. The case that I did was a compound volvulus, so the sigmoid colon had twisted, then 1.5m of small bowel had wrapped itself around the volvulus and died. The sigmoid was so far gone it was green and about to rupture. This is something I have read about in textbooks and thought "that never happens." Clearly it does, and respecting a huge amount of bowel is quite hard work. But he is now much better, all the ends are joined (stomas are not ideal here so we avoid them at all costs) and I think he might make it. Certainly he is up and out of bed this morning!
I'm on call this weekend, and arrived yesterday morning to be presented with a 13 year old with a splenic rupture by the night staff. He proved really tricky - most people here have huge, fragile spleens due to malaria and his was twice the size it should be. He had injured it in a really low impact injury two weeks ago, then become progressively more unwell. Ideally, we try and avoid removing their spleens, because they are then incredibly vulnerable to infections (mainly malaria here). It is also unlikely that they will take the necessary antibiotic and antimalarial prophylaxis for the rest of their life. To do this, you have to try and work out if they have stopped bleeding on their own. You also have to assess the risk of them starting bleeding again (higher than at home because of the pathologically large spleens). If we had access to a CT scanner, it would have been really easy to tell if he was still bleeding. We didn't, so we watched him for the day, then decided he was getting more unstable and took him to theatre. Sidney was still around, so he came and helped, which meant between us we had done two precious splenectomies. This was a nightmare, because it was stuck fast to the underside of the diaphragm and I actually put a hole in the diaphragm while getting it out. But, after taking out the shattered spleen, the 2 litres of blood in his abdomen and fixing his diaphragm, he is in good shape. This morning he is complaining about his catheter, which I take to be a good sign.
I have just returned from taking a 3 year old to theatre in a hurry. He had received some chemo into a tissued cannula a few weeks ago, resulting in a huge wound on the inside of his elbow. We had debrided the wound and skin grafted it this week. We brought him in today for a graft check, to discover the whole area was infected, the graft was dead and what looked like his brachial artery (the main one in the arm) was shooting blood across the room. So we took him to theatre, set everything up for a major vascular case (there are even some grafts in the cupboard, although they all went out of date when I was still at school) and phoned the Prof (who is in Lusaka) for a spot of advice. In classic form, he gave me a solution (vein patch or take one of the veins from the leg and produce a venous bypass) and signed off with "good luck!" Luckily, when we opened things up the artery was intact and it was just a bleeding side vessel.
Now I'm just waiting for the next emergency to come through the door (from the barbecue at Nat and Will's place, Carlsberg don't do on calls, but if they did.......)
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