Go slow or go home

Having gotten a surprising amount of sleep last night (almost 8 hours!) after my 12 hour shift in the OR the previous day, I felt well rested this morning. The edge of a headache however rattled at the back of my brain. I suspect dehydration is to blame despite my efforts to drink water constantly. The shower seemed particularly low on pressure and hot water had long since been given up on. As we piled into our transport to the hospital I hoped our OR slate would be more punctual than yesterday.

Then we hit this insane wall of rush hour traffic. Or as the Ugandans call it a "goslow". Well this 'goslow' was a pain in the ass. Bodabodas (those deathtrap motorcycles) squeeze beside you and pumping raw, unfiltered exhaust through your window. Sadistic traffic cops direct traffic into each other. Vendors shove prepaid cards in your face (though cell coverage here is awfully cheap). As we arrived security had been pushed up considerably. When I asked around about this the driver explained that Mulago hospital is a high value target for terrorist attacks being a large government facility. Recent threats and bomb attempts have put security forces on higher alert, explaining the increased military and police presence. Bodabodas have now been banned from entering as they are popular vehicles choices for suicide bombers. This has all been exaggerated by the significant increase in traffic and patients to the hospital recently, along with it fake security personal and doctors extorting patients and visitors. As far as I'm concerned the only acts of terrorism is that stupid bloody red line system they have here.

On a related note and a story I didn't relay yesterday, you may have seen it on the news but a fire broke out at the King's residence (there is no king of Uganda, but each province has a king). We were called to casualty to find 4 significant burns, one with 100% burns and another  with over 90%. Two other suffered less severe burns but still needed medical attention. Today it turns out that the woman, one of the severe burns, had started the fire, flinging a jerry of petrol onto a check point after a previous altercation with security. Both her and the guard, likely her target, were considered palliative on sight. It was hard to disagree with the decision. Regardless all four were quickly swept out of Mulago to a private facility and out of the public eye.


We arrived at the hospital later than planned but I suspected we would still be the early ones. Minutes within arriving we were asked to see a new emergency.

A young girl, 4 and half had grabbed a live electric line hanging from a transformer on her way to school. A common crime in the country is the theft of electricity. People siphon power off a power line to their homes but then disconnect the illegal line during to day to avoid being caught. This leaves dangling live wires hanging from poles and as a result, electrical injuries are quite common. This sad thing had grabbed the wire with her left hand, which then arced down through her arm, through her chest and out. Much of the hand and two fingers were charred beyond function as well as a sizable hole in her torso. She was stable but the complication of these injuries is profound internal injury. High power electrical injury causes swelling and hidden trauma of the tissue where the charge traveled. Bone shatters, muscle dies, tendons and nerve snap. All of this hidden under the surface with only the entry and exits points showing any visual sign of injury.

Electrical injuries, especially in children have high mortality rates. Quick an appropriate treatment is critical. Sadly, if we had not been here, she would have languished  on the ward and at best, lost her entire arm,

We brought her stat to the OR and after quick inspection, amputated the two fingers and debrided the burnt chest wound until a large hole remained which we then closed using a special "Limburg" flap, a technique using geometric patterns to mobilize loose, normal tissue in one area to a defect in a another. For the arm,we performed a fasciotomy, a surgical release of the muscle compartments, to allow post injury swelling to expand freely, rather than compress and kill the vascular supply to the limb. With such early intervention the arm should survive and the child should make a reasonable recovery, less two fingers, assuming her heart, which was in the path of the arc, doesn't fail.

Post op, the arm now splinted while the chest defect was able to close with out skin grafting, giving a much better cosmetic outcome as well as lower risk of wound complication.

Recall that the burn ORs take place in a different section of Mulago hospital. The room itself is the size of a small bathroom, with an even smaller preop area beside it. The change room is a policebox sized closet with a curtain for a door. Except unlike a Tardis, it is actually smaller on the inside than it looks from outside. Except for the size, the burn OR ran similar to the other ORs. It also has a red line of death, though the staff there are a little less psychotic about it. All the sterile instruments are kept in a big random pile that is taken from during the day. The nurse picks through for what you ask for with a long pair of tongs. Often you end up getting something different if she cant find what you want in the pile or gets bored looking. If you run out of instruments before the end of the day, this often forces you to cancel the rest of the cases.Cautery machines spark out from open electrical ports, many with burn scores up the wall from previous electrical fires. Three of four bulbs were burnt out on the OR light, good thing I have a headlamp.

Tight quarters doesn't begin to cover describing the Burn operating room.  Note the surgical light with all but one of its bulbs out. "But there is a second light stand there" you say? None of the bulbs work in that one.

We were already behind schedule as was our other two ORs in the main operating theatre. The nurses had held off on their strike, pending the arrival of their lunch that is, but were clearly less than enthusiastic about keeping things moving. Adding to this, one of our anesthesia machines had been highjacked by ophthalmology for cataract surgery. We would have to steal that back.

Of course no day would be complete without a ball bashing by the red line Gestapo. After another speech on the importance of keeping things separate to maintain a clean facility, two big fat geckos pranced across the floor between us. Geckos. Fat ones. I gave him one of of those crooked eye brown looks and he ran to get a dust pan. I hope the geckos got away.

Another consult we were asked to see, During a robbery this woman was shot at point blank threw her collar bone and out the back (note the small exit wound) damaging her brachial plexus, a critical junction of nerves coming from the neck to the arms. She has no function or sensation in her right arm now. She may partially recover but the surgical expertise to repair this injury is no where to be found in the region other than two members of our team.

The next few cases were post burn scar contracture surgeries. Poorly or non treated burns can often heal with profound scars that tighten and limit movement to that area as well as cause ongoing pain. We identify the main tension areas of these scars and surgically release them, filling the new gaps in the skin with grafts. By afternoon lunch had arrived, a simple affair of rice, potatoes, mystery meat and a few other starches, The nurses seemed satisfied and work continued. The day ended with a joint OR with orthopedics to cover a hideous open wrist wound with a skin flap in a man who crashed his car with his arm out the window. The residents were intelligent and eager to learn. One ran music, a random series of movie soundtracks, challenging us to identify the movies of each. Meanwhile the other team hacked a tumour off a leg that encapsulated every artery and nerve in the limb (you might recall it from a picture from several days ago). By the end of the case, my OR shoes were caked with blood, the original colour almost undetectable.

A college and myself elevating a flap off this man's lower abdomen to fold over and cover a large wrist defect following a motor vehicle crash with his arm hanging out the window. 

He will be tethered to this flap, which is still connected to his abdomen, his arm taped and bound in position, for about 3 weeks until a new blood supply establishes itself from the wrist and it is safe to divide the flap free from the abdomen.

After a full day's surgery, I pity the person who has to clean this up...assuming anyone cleans the ORs. At least we have that red line.

We got home later that evening. After getting fleeced by the taxi driver, they don't use meters so the price varies depending on how pale your skin is. A huge dinner was waiting for us: Local curry dishes, rice and roasted chicken for the carnivores. We set up tables outside on the grass and I listened to people rave about the virtues of tandem biking while I planned for the next day's work in my head.

I'll be in touch.