My arm is complete again!

Today was completely a medical day. No fun trips out and about. No time to sit and reminisce about the myriad of things that I’ve seen here. Ok, that’s not exactly true. I did have some time in between cases, but I’m reading a Thomas Hardy novel that I hadn’t heard of before, and the sentences captivate me. In sheer length alone! But conjuring up deep thoughts and trying to sort out the meaning of it all is not a task to be cobbled together with spare minutes. That’s a full day’s reflection. Perhaps I shall have to reflect by the shores of Kiboko Bay this weekend… ;-)

When I first arrived in theatre today, the intern began telling me about a blunt trauma case. A young man knocked down by a motorcycle trying to cross the street. He was haemodynamically stable and his exam was notable for some left-sided abdominal tenderness. The first thought that flitted through my mind, typical American that I am, get a CT scan and we can probably watch him in the ICU. Silly me, forgetting where I am.

Instead, we took him to theatre. Where, I, with a grand total of 2 splenectomies under my belt, took out his spleen. (Yay! Three!) And it was a simple laceration, Grade II at the most. He could have kept his spleen and not gotten a huge midline incision were conditions a little (a lot) different here.

In theatre, I was a little disappointed. The intern that is on call this week (and hence has theatre privileges for any emergencies) is one of the interns that stands out in her class. She knows her patients and performs well on rounds. I’m not sure if that makes her really good, or if she looks good by comparison. I know I’m expecting a lot of an intern, but she does not have great hands or eyes or common sense. I did two cases with her today (more on the other later), and despite gentle instruction, there was no improvement or even a morsel of understanding as to what I needed her to do to assist me!

On to emergency case #2, a woman transferred in from a district hospital with multiple pathologic fractures(pathologic = due to a disease process, not necessarily trauma) and a large bowel obstruction. Because of the report of the abdominal x-ray, concern was raised for over distension and perforation. First, I’m trying to teach the interns (not just me, but the surgeons here) to re-examine and re-evaluate the patients that come from the lower levels of the health system here. The way the national system works makes it unclear if a physician has actually seen the patient as many sub-district centers are staffed by clinical officers, whose training is variable and difficult to define. Secondly, the abdominal xray was clearly showing dilated small bowel, not large, and risk of rupture is much, much less (if not completely infinitesimal). She was comfortable with a tube decompressing her stomach and after an enema with some results (if you know what I mean). Back in the good ol’ US of A, we’d have gotten a CT scan, which would have shown what it took a foot-long incision to show me: a non-obstructed dilated small bowel, likely just an ileus (a discoordination of the bowels, usually because of pain medicine).

When I left theatre after that case, I was told there was another. A three year-old girl that had been struck by a motorcycle trying to cross the road. The staff told me that it would be about an hour, so I changed back into civilian clothes and went to the hospital canteen to get outside for a moment or two.

Upon my return, all seems ready to go. The child is on the table and the anaesthetist is ready to put her to sleep. I ask the nurses to inform the surgeon that we’re starting. Despite the fact that he let me do the other two on my own, I wasn’t really comfortable with doing a pediatric case on my own, particularly a splenectomy, which is what I was anticipating.

Wonder of wonders, he didn’t know about the child. The intern that booked the case never told anyone, just stuck a sheet of paper on the theatre board. AND, felt that he had covered his tracks by documenting in his note. “Prepare for theatre, unable to reach consulting surgeon by phone.” The surgeon (who happens to be head of the department of surgery) was running the monthly department meeting and so sent his colleague in to do the case. After the conversation I had with that surgeon, I am very happy that I am not the intern that booked that case. He might need his spleen taken out soon!

This case turned out to be less disappointing than the others, because while the others could have been managed non-operatively, this child had a complete fracture of the spleen and it needed to be removed.

It may seem to you (if you’re medically inclined at all, or even just curious) that there is a lot of spleen injury in Kenya. What I learned today is that the various infectious diseases that are endemic here, particularly malaria, cause enlargement of the spleen. Additionally, there can be fibrosis and adhesions that would be unexpected in a Western population. It becomes a bigger and more tethered target and gets injured even with low energy impact. And that, ladies and gents, is your East African fact o’ the day.

My last four cases have been exploratory laparotomies, watch tomorrow end up being a whole lot of ortho just to balance it all out!

G’night all!