Travelling Graham

Following the choas of my second week, including falling asleep in theatre standing up at 6am (at the end of Friday night's on call) whilst helping in a laparotomy (full open abdomen operation) for a gunshot wound, week three was a slightly more sedate affair.

I was allocated a ward of my own (female gen surgery) in the hospital and became responsible for 4 or 5 ladies with a wide variety of problems. Mrs B has Diabetes (a common problem) due to obesity and has had to have both of her feet amputated because they died from lack of blood flow (a common problem when diabetes is not well controlled). She is awaiting a revision operation for her left leg stump so that a prosthesis can be fitted thus enabling her to walk again.

Mrs N is morbidly obese (also diabetic) - she was admitted in Friday evening with cellulitis (severe infection of skin and soft tissue) of her leg which needs immediate antibiotics into the blood (intravenous). At the moment she is doing well but her obesity means that she is not very mobile and so I think that, combined with the diabetes, her infection could be hard to shift and we will have to be careful that she does not lose her lower leg.

Miss J is an unfortunate case, she is 17, HIV positive and has had three previous operations. The first removed a cancerous womb, the second a cancerous nodule from the liver, and the third an entire lung which also had cancer. Problem is that the experts have no idea what type of cancer it is, and so we are waiting on Durban to find out how to treat her - the prognosis is not good, she is very thin and has no energy.

Miss H, also HIV positive, was admitted with a large abcess in her thigh, she had this drained and we are waiting for the lab to tell us which bacteria is responsible - mean while she is on a strong cover of anibiotics, the odds are that it is TB so we could start her on TB therapy, but this is a 6 month course and can be quite unpleasant to take.

One of the most important things I have learnt here is this. 4 things cause illness in Kwazulunatal:
1. HIV - about 40%
2. Diabetes - type II late onset related to obesity
3. TB - endemic in the population
4. Agression and violence

There is a basic rule of thumb. If they are fat, they have diabetes, if they are thin they have HIV/AIDS, if they are coughing or have abcesses it is TB and all other cases are Motor vehicle accidents or violence. This is obviously not true, but it is quite scarey just how often it is true. It is indeed possible to identify someone with aids just by looking (wasted muscles, no fat, skin lesions, no muscles in the temples) but quite impossible sometimes to identify HIV carriers and for this reason it is so important to be so very careful.

The irony is that these patients need medical assistance mch more than everyone else, but that medical assistance is so hard and expensive to provide because the medical team must first be safe, and Africa just does no have the money to fund this all.

Chao

Today the machine which reads blood results broke down so we have no Liver enzyme function readings,these are basic investigations for ill patients. The other day, the X-ray department ran out of processing chemicals so we had no X-rays until they re-stocked. Meanwhile the CT scanner can only do 15cm before it overheats. These are investigations that are taken for granted in the UK, the nearest referral centre from here is 2 hours away, and many of the patients are not stable enough to be transported (let alone the fact that it is logistically impossible to do this) so basic clinical skills are vital in assessing patients.

Work becomes very difficult.

It seems that this week has been neverending, I worked 76 hours including two on calls. It really leaves you drained but the medical experience is huge.

Highlights included my first operation ever - obviously very simple and highly supervised, but nevertheless, everyone has to start somewhere.

This is me about to perform my first operation whilst on call on riday night of week two. I am cleaning the thigh of a man who has a TB abcess.

Once the pus is drained, Drainage of Abcess (warning, this is not a video for the feint at heart) you have to remove all of the infected tissue with your finger...

..and then wash out the hole with antiseptic. To finish you place drains in the wound and bandage the leg.

This chap was stabbed in the elbow and his brachial artery was cut. This supplies the two wrist arteries and the hand so needs to be mended! The Artery is first disected away from the surrounding tissue before the two ends are joined with tiny stitches - a blood clot destroying drug is passed into the vessel to stop it from blocking.

This man was shot through the abdomen by a 7.62m sniper rifle. You can see the entry hole on his right side and the bullet shock wave has pulled 20cm of Colon through a 5cm exit hole in the muscle wall. He was very lucky as the bullet only grazed his liver. 2cm higher would have killed him. He was patched up and the hole in the Colon was stitched.

This man was shot by a low velocity 9mm pistol. You can see that the bullet is lodged in his upper left abdomen (top right of picture). This slower bullet caused more damage as it had stayed in the body. This means that all of its energy has been dissipated inside the body.

These lovely ladies are our lifeline to the patients. They translate our consultations with the locals and organise all of the tests and treatments. 3 consultations take place in each of these small rooms at one time - good for confidentiality!

This man turned up with a massive abdomen. He had a pseudocyst in the abdomen which is labelled above. We drained over 7 litre of fluid. Unfortunately this is part of end stage cancer so although we have made him more comfortable and he will leave hospital - his future is not very bright.

Sunday and a day off, we went 2 hours north to St Lucia and Cape Vidal on the coast where we snorkled and saw many shoals of fish including stingray.

This picture was taken after we had just performed a total mastectomy with axilliary clearance, the patient is still on the table.