My name is Barry Hicks. I am a retired surgeon who worked as a surgeon for 50 years – half that time in Australia and half in Africa, mainly Ethiopia. I have thoroughly enjoyed my life as a surgeon. In Ethiopia I was associated with a Christian mission but worked most of the time in a government hospital or as an Associate Professor in two of their Universities. We saw many things not commonly seen in Australia.
I have been married for 57 years to Robin. We have 7 children including 2 ex-Ethiopian, now Australian, young men. I retired from Arba Mintch University at the end of 2017 and we now live in North Queensland on a small farm.
In down country Ethiopia we used to say that in interpersonal trauma the rich – shot each other; the middle class knifed each other; the poor speared each other. We saw many other cases injured with digging hoes, machetes, stones etc, but the case for today was a spearing in the late 1960’s.
A young man had been speared about 4 days previously. They had kept him at home I suspect because they thought he would die. It was an intra-family dispute and they didn’t report it to the police as they understood the reason for the fight and didn’t want the one who wielded the spear imprisoned. He was family and families sometimes fight!
The spear went in his back on the left side and was protruding out of his left upper abdomen. He was not shocked, he was not infected, he was obviously in need of treatment – so no doubt he would have all lots of imaging today but all we had was an old ex-army X-ray machine. We did all the basic things; there was an urgency but not a frantic one so, after an IV was inserted and antibiotics given, he had a thorough clinical assessment, blood was taken and two relatives were sought to give blood. He was taken to the operating room and after the double lumen tube was inserted the spear was removed. (I had to give my own anaesthetics, but fortunately had before training as a surgeon done a bit of anaesthetics and in my surgical training done some thoracic surgery.) I don’t remember the surgery well except that surprisingly little damage had been done to anything. He ended up with an UWSD chest tube in place and a laparotomy scar. He did very well, got on well with the other men in the ward, and was doing extremely well. His chest was good; he didn’t have any unexpected abdominal findings; there were no signs of deep vein thrombosis. On the fourth postoperative day he was laughing and joking with the other chaps, sat up, still laughing, and fell back dead.
I know of only 3 things which cause people to die like that post-operatively. A massive embolus, a massive heart attack and a cerebral incident, a massive stroke. He was young and healthy and I’m sure had an embolus. We didn’t have any anti-coagulants in the hospital so we couldn’t use prophylactic doses against clots. At any rate we saw very few deep vein thromboses, which we of course had to pick up with clinical testing as we had no ultrasound, and often there is no tenderness in emboli which give off massive clot emboli.
At any rate he was instantly dead in a ward in our general hospital, about 500 metres from our operating room which was in the leprosy hospital. Tragedies happen.
I decided today that, as I’m about a month ahead in the daily devotional articles As I read it (plainly understanding the Bible) that I produce, it is time to do a medical article. So I decided to open my photo gallery and just write about a picture. I love kids so I’ll go to the paediatric section and I’ll choose a not very gory picture and see what memories it brings back. Gory is a relative word and so I’ll put the picture at the end, so that unless you choose to see it and press the ‘more’ line you can just consider what I write. And I guess that I am using this example to show you the number of issues that lie behind almost all patients whom you see as a practicing surgeon.
In the Ethiopian Orthodox church circumcision is practiced according to the law as laid down in the Old Testament for the Jews. They go further in that they do it for both boys and girls. Usually it is performed by a neighbour who may have experience but is not qualified. The Muslim population do it in on much older boys and in some of the animistic areas they even delay until they are of marriageable age.
I refused to be involved in female circumcision as a prime agent but sometimes was drawn in later on. I remember a family bringing their twins a boy and a girl. They were maybe 4 0r 5 years old. I made a booking to operate on the son but after explaining why I thought girls should not be operated upon, I refused to do the daughter. The boy’s procedure went well. That evening I was called back to the hospital urgently. A neighbour had ‘operated’ on the daughter. She was brought in shock and still bleeding. Question – should I have been involved primarily? She survived and I hope that the community learnt a lesson. Note please almost all girls are circumcised and this sort of complication is rare.
Most have learned not to perform the procedure if there is some anatomical abnormality, which occurs with a 1/1500 live births. The prepuce is frequently used in repair of an abnormal situation. Fortunately the young teenager I am about to describe had not been circumcised. This boy had 2 problems a) he had hypospadias and was urinating from a hole about half way along the shaft of his penis, and b) he had a moderate chordee – that means that when erect his penis was curved, in his case downwards and through about 45 degrees. As a little boy this created few if any problems but when he urinated standing up he had to be careful not to urinate onto his own legs or clothes. Obviously it later would cause problems with intercourse. So he needed surgery, which in a well doctored country would be done by a paediatric urologist. At the time there was such a specialist in the capital. As about 90% of people are rural and in the capital there are about 8 million people at any rate, it is not possible to refer every case! When I operated on my first such case I had never even seen a case like this operated upon. Most people consider that area of their body ‘private’, but are still very conscious of it!
Over the years I have seen a number of diaphragm injuries. Four come to mind as very interestingly different.
While I was doing a lot of chest surgery, I received an urgent call to come to the OR, where a an obstetrician friend was doing a Caesarian Section. The patient had been in a car accident a couple of years before, and had gone through pregnancy well until when on the operating table, having been given a dose of scoline her left chest became dull and the anaesthetist had to struggle to keep her oxygenated. She had a rapid LSCS making it much easier for the anaesthetist. You could hear bowel sounds in the chest, so with her accident story, we diagnosed delayed rupture of the diaphragm, probably by the rupture of her incomplete tear with the twitches caused by the scoline. She was repositioned and her diaphragm repaired. She and her baby did well.
A man had been caught between a backing utility and a bench several years before. He was referred to me with a large AAA and a ruptured diaphragm. At the time he had been investigated and no problems found. After work up, and postulating that his prior accident had probably damaged his aortic wall allowing his aneurysm to develop, and that its size had caused an incompletely ruptured diaphragm to completely tear, he was operated on. We repaired both problems at the same time. Obviously this time the diaphragm was repaired from below.
A grossly obese woman unwisely sat on a glass table. She had a stab wound in her right back, and was operated on by a general surgeon who at laparotomy found a little blood but no other problem and closed the abdomen. She survived but was not well. They did a chest X-ray and found a mass in her right lower chest. I was asked to see her and after investigation explored her right chest finding a complete cut across her diaphragm with the liver totally in the chest. With it repaired she made a rapid recovery.
The fourth case was seen when one day I made one of my weekly trips to Nazret Hospital when living in Addis Ababa. There was a man who had been stabbed in the back of his right chest. There was an UWSD in place to treat the pneumothorax. He had no abdominal signs or symptoms. But no one had noticed that there was bile coming out the drain! I explored his chest and found about a 5cm laceration in his diaphragm and a considerable laceration into the bare area on the top of his liver. I repaired both liver and diaphragm through the chest. He did well.
A few years ago I wrote a book, probably better called a booklet, for my students as they began their clinical surgical courses in fourth year of a six year course. It was relevant to their situation with lack of facilities and language difficulties. Their ability to read thick tomes was limited, so I tried to put the very relevant stuff in a compressed form. As I meet a new era of Western students sold on investigations, sometimes seemingly before physical examinations, I’m convinced that it may be of use to them also.
It is due to be published as an ibook on November the 27th.
I am pleased to commend this practical surgery help book written by Associate Professor Barry Hicks.
Dr Hicks is a surgeon with vast surgical experience in both Australia and Ethiopia, having taught, conducted clinical work, and operated in a number of hospitals throughout Ethiopia over a 50-year period. Dr Hicks has included photos from his extensive collection accumulated over his years in Ethiopia and this is therefore unique as it included many photos of advanced pathology seen in rural Africa. While this is a small book written initially with Arba Minch medical students in mind, it is packed full of practical surgical tips for students and doctors alike and it may be of help to many in training.
The format is that of a very personal but practical description of what information is common and important, as well as other lists and facts covering many areas of surgery. It takes a systematic approach to the human body and surgical conditions. It is small enough to sit in a medical student’s or doctor’s pocket or be loaded on to a phone so that it can act as a ready reference for both elective clinical ward work and the emergency situation. It should be read, memorised, and kept handy for refreshing knowledge as needed.
As a surgeon working in the DR Congo, who has regarded Barry Hicks as a mentor for many years, I commend this booklet to you.
Dr Neil Wetzig AO; FRACS; FRCS (Eng.); FCS(ECSA)
Consultant and Advisor of Surgical Training Programs, HEAL Africa Hospital, Goma, DR Congo
I wish that I had had better investigative equipment. I wish that I had had more energy and time to write things up on the spot. As we all know you cannot relive the past. So in my old age I dwell among memories. Some of them very special memories. And that includes this little girl.
She presented short of breath with a high fever, a very tender neck and looking into her mouth you could see a big retropharyngeal bulge, which meant we knew why she had her temperature and was having difficulty in breathing but that bulge was abnormal in a kid of that age in my experience. The X-Ray quality was terrible. We did not have CT scanning or even a decent viewing box in the wards. The following picture shows how we looked at films.
We tried for a soft tissue lateral film and a lateral bone film.
Please don’t be too critical of the films! In the upper soft tissue film you can see how far the air tube is away from the cervical spine. In the lower bony film you can see two bodies which look abnormal.
Where we were, you did something or let nature take its course! Your decision may have been very different from mine but we
Decided that it probably wasn’t TB and started her on high dose antibiotic.
With oxygenation and gentle sedation I did a tracheostomy under local anaesthetic.
We aspirated a huge amount of pus through a large needle through the mouth when she was fully anaesthetized with the trachy in place. This was sent for mcs but had to go to a private lab outside the hospital.
Made a POP encircling her forehead, strengthened a strip down the back of her neck and encircled the chest.
It was not TB but sensitive to our antibiotics. She was on this treatment for 6 weeks, except that her trachy was removed after several weeks when her temperature was down, and by testing she could breath around the tube comfortably.
Either inspite of us or because of us – she got better and went home after about 10 weeks. She wasn’t always happy to have a photograph taken!