Enhanced recovery?

Not infrequently, we lament the death of a post op patient and say "if only we had a ventilator/inotropes/parenteral nutrition/haemofiotration..." Indeed, comparing what is available here to what is done in England, I am regularly amazed at how many survive despite the lack of ITU facilities - a point floridly demonstrated by two cases from this week.

The first was an 80 year old lady. It is fair to say that 80 is "a good innings" in this part of the world, and they will have been 80 hard years working the fields. I didn't ask how many children she had, but the average is something around 8, and it is probable she has outlived them all. She arrived on Monday afternoon, and the clinical officer was sufficiently worried about her that she called me out of theatre to see her. She had had bowel obstruction for 5 days, was peritonitic and shocked, but after a bit of fluid perked up and we took her to theatre. She had a compound sigmoid volvulus (small bowel wrapped around large bowel wrapped around itself) although it was not necrotic (dead) which seems par for the course for this problem. Anyway, we proceeded to resect the offending bowel, which proved tricky to get two healthy ends together, so it took just over an hour in total. For the majority of the hour, we could hear the pulse oximeter beeping away in atrial fibrillation, and the anaesthetist complaining about the blood pressure. Indeed, he turned the anaesthetic down so much we had almost no space in which to operate [This is because the patients muscles start to contract again, closing the gap in the abdominal wall]. Having finished, she looked dreadful. Her starting haemoglobin level had been half the norm and she had bled a bit. The single available unit of blood had already been given. We put her on oxygen and fluids, and hoped for the best. Even in England, I suspect she would have a high chance of dipping in the immediate post op period. However, within 36 hours she was sat up, eating and had opened her bowels. She is now home. Some people are just made of tough stuff!

The second was at the other end of the age spectrum. I was walking through Kizito on Thursday afternoon and the nurse asked me to look at an ultrasound report for a new admission. I was a little bemused, as I had been in clinic that morning and thought I'd seen all the new admissions. However, as happens quite frequently, the really sick patients are sent straight to the ward by the clinical officers, even when we sit in the room next to them, and we are not told! This 7 year old had been run over by an ox cart, with the wheel going across the middle of his abdomen. While he looked remarkably well and had a normal heart rate and blood pressure, he was peritonitic, indicating some form of abdominal catastrophe. He turned out to be even more anaemic than the previous patient, and had a belly full of blood and two sizeable liver lacerations. This was however a solitary injury and all was in control once we had packed the bleeding points. After a few sutures to repair the liver and examination of the rest of the abdomen we closed up, and within twelve hours he was sat up, looking well and eating. Again, a remarkably fast recovery from a major injury.