Referral

I was once told by a tutor in Cambridge that the only question a doctor really needed to be able to answer was "can I deal with this?" and if not, "who can?" This is a perfectly reasonable approach where there are multiple specialist centres, well staffed with a range of experts, all linked by excellent, affordable transport links. Unsurprisingly, that is not the case in Zambia. The concept of referral is therefore very different from at home.

St Francis' receives a huge number of referrals, most from the Katete district health centres, but a sizeable number from other district hospitals (particularly Nyimba, Petauke and Lundazi) and a lot even from our regional referral centre in Chipata. As I have hinted at in previous posts, we have the only surgeons in the province and so it makes sense that all complicated cases come to us. The other hospitals will however provide some basic surgical services, including Caesarean sections, hernia repairs and fracture management. Referrals, particularly of sick inpatients, arrive in a hospital car, which is often sent only when full. This means we often only see the very sick and unmanageable, or inadequately managed patients from the referring centres, giving us a somewhat distorted view of their work!

The patients we receive generally come for a specialist opinion, which is quite often a disappointing (to the patient) "do nothing". Common examples of this are fractured clavicles, acromeo-clavicular and sterno-clavicular joint dislocations or terribly advanced cancers. Nyimba quite often sends a car on a Thursday evening, which means we occasionally get someone who has had conservative management of an abdominal catastrophe for several days who then needs an emergency laparotomy at night, which can be somewhat frustrating! [Particularly for the Surgeon's wife! - Ed] Others include complications that are related to treatment at the other hospital. Our gynaecologists always have at least one C section complication from elsewhere (normally a ureteric or bladder injury). We most commonly receive problematic open fractures or closed fractures that can't be reduced without performing an internal fixation. This week's disaster was a young man with a degloving injury of his leg and a Gustilo 3 open ankle fracture which had been sutured at another centre one week earlier. We had to debride a huge amount of dead tissue and apply an external fixator, and now it is looking like he will keep his leg.

We also receive a lot of self-referrals, some who are convinced we can do something they have been denied in the main hospital in Lusaka (some are right, like the chap who travelled 8 hours to have a lipoma removed this week, some are wrong, mostly those with complicated urological problems) and others who just want treatment at what is perceived to be the best hospital available.

Perhaps the oddest referral yet came from a wildlife charity worker, who arranged to send a young boy whose chronic osteomyelitis and exposed tibia had been mostly ignored by his local hospital.

Our access to referral is a little more tricky. Most patients have neither the will nor the money to travel to Lusaka. When they get there, I understand they have to wait for treatment, further adding to the cost. Most will ask us to do everything at St Francis', and I'm sure a significant number of those we do refer on actually just go home instead. So, we try and offer as much as is safely possible.

The question of "can I deal with this?" became somewhat more complicated last week, as due to a clash of annual leave, I was less supported than usual. There is no such thing as a critical care transfer, so if someone is profoundly unwell and needs emergency surgery they either die or have surgery here, by whoever is available.

I am working on the principle that if I do nothing and the result would be worse than if I do something, even if things go wrong, then I should do the most straightforward operation possible. So, while I am still sending off our complicated urology cases (we get a lot of advanced bladder cancers and difficult gonorrhoeal strictures), I have taken on a bit of orthopaedic work beyond my usual UK experience (open reductions of supra condylar fractures and external fixators mainly) and had to take on one complicated laparotomy (a relative decided he did not like the look of the ileostomy we had brought out for a typhoid perforation, so forced it back inside the abdomen). We also (despite not being plastic surgeons) performed a pedicled groin flap to resurface someone's hand. He would not have gone to Lusaka and just gone home with a terrible wound if we had tried to refer him. The flap looks great, and if it had failed we could have done a skin graft, which was our worst case scenario if we didn't do the flap. So even a failed operation would have been no worse than no operation.

Gemma is now back from her interviews, so I have a consultant around all the time again. Last week did however provide an interesting insight into learning my limits and the often complicated decision making around taking patients to theatre.

I have been looking at some interview skills websites for when I get back, and was amused to see a discussion of the question "a patient needs an emergency operation that you have no experience of, and the consultant is unreachable - what do you do?" The answer listed a whole range of options, through calling other consultants, calling other hospitals, calling the MDU and only then considering doing the operation if all else fails. I am somewhat looking forward to the reassurance of having such a wealth of opportunities for help when I get back!