There are no minor patients

It’s Thursday just before noon in Paoua. I have been here for one week.

It’s Thursday just before noon in Paoua. I have been here for one week. The pace did slow a bit after my first two days (though we did need to get up at 2AM this morning to deliver a baby by c-section…his hand was over his head obstructing the natural way out).  I think I have settled into the hospital routine though am still learning about where everything is and what everyone does. There is a “morning report” at 7:30am every day except Sunday, attended by the all physicians, the head nurse and charge nurses and some other clinical staff. Here the medical doctor on call for the previous night reviews all the new patient admissions. After report, I change into scrubs and make hospital rounds with the anesthesiologist and the nurse in charge of the OR, seeing our old patients who have had operations and any new patients who may need them. Next we return to the Bloc Operatoire, the building that contains the main OR, a smaller OR used for simpler procedures and dressing changes, all OR supplies including sterilization equipment and several smaller rooms including the OR office, our changing room and a room for patients to undress and be examined.

I have performed 25 operations since my arrival. Other than the two laparotomies described in my last entry and the caesarian sections, they would all be considered minor surgery at home. I have done 13 operations to incise and drain abscesses, 2 groin hernia repairs, 2 skin grafts and one orthopedic manipulation under anesthesia. These are not operations that a young surgeon dreams of doing (at least I didn’t when I was young) as they aren’t particularly technically challenging nor glamorous. I doubt that any surgeon “Grey’s Anatomy” (an American television show about surgery and surgeons and romance) ever ran to the ER to drain an abscess or repair a hernia. But at the risk of being too boring for American television, I will talk a bit about these 18 “minor” surgeries.

In Paoua, abscesses are a common problem. They seem to occur in all ages, from the very young to the very old. In the absence of hygienic conditions (such as easy access to clean water, dry clothing and a clean place to sleep) a small injury, insect bite or even a scratch can easily become infected. If the skin heals over the infection, the abscess grows and forms a collection of pus, sometimes surprisingly large. If that isn’t drained properly, the abscess will develop into a life-threatening infection. Nine of the 15 abscesses that we have drained this week have been in children between the ages of six months and 10 years. Every one of those was brought in by a parent with the universal look of concern for a sick child in their eyes.

Groin hernia surgery is generally an elective operation. In the US, it is often done before the hernia causes any symptoms and is scheduled around the patient’s work or vacation schedule. My two hernia patients this week have had symptoms from the hernias for years because of strenuous lifting and extensive walking in their daily lives. They are at risk for developing a strangulated hernia at any time, possibly during a period when there is a “gap” at the hospital without a MSF surgeon present. A strangulated hernia is when the intestine gets “caught” in the hernia. Without an urgent operation to repair it, a strangulated hernia leads to gangrene of the intestine, followed by peritonitis.

The two skin grafts and the orthopedic manipulation are in patients who suffered burns. Burns are common everywhere in the world but in a region where people don’t have access to modern burn treatment, minor burns that cross a joint can easily become a chronic debilitating problem. Our skin graft patients had both suffered burns over the foot and ankle, their initial burns occurring six months and a year ago respectively. The woman whose burn happened six months ago has lost range of motion at her ankle with a foot drop that interferes with walking. The young man whose burn happened a year ago has calf muscles atrophied from disuse. The third patient is a young woman who burned the elbow on her dominant arm one month ago. She has a raw, non healing wound over the elbow and because of the pain she has kept the arm straight with the elbow extended. When I met her, she held her baby in her left arm with the right one hanging by her side with limited range of motion at the elbow, essentially useless. The first step in her treatment was to break up the scar tissue and “unfreeze” her elbow joint by moving it carefully through as wide a range of motion as possible, a so-called orthopedic manipulation done with her under general anesthesia. She will now need dressing changes until she develops a healthy, uninfected bed of “granulation” tissue over the elbow, then a skin graft. The healing will likely take over a month and her graft will be done by another surgeon down the line.

The hospital has the tools a surgeon needs to do skin grafts, a first class electric dermatome and skin “mesher”. I used them for our two patients on Tuesday and Wednesday. We can only do one skin graft a day because of the need to sterilize the equipment. If we had two sets of equipment we could do two a day, plus have a spare in case of mechanical problems with the dermatome. At home I would leave the sterile dressings from the OR in place for several days before examining the graft and donor sites. Because I am worried about the increased risk for infection and graft loss here, I changed the dressings this morning; I was happy to see that the grafts are taking 100%.

That sums up my 13 minor operations for the week. When a surgeon is disinterested or nonchalant about doing a “minor” operation, he/she should think of the famous quote by Stanislavsky “Remember: there are no small parts, only small actors” as a metaphor for our trade.  Although not terribly glamorous, the good that will come from these operations to our 13 patients and their families is major. Maybe the saying for surgery could go “Remember: there are minor operations but there are no minor patients”.