A problem of insufficient Investigative tools.

I’m sorry but I don’t have a picture of the patient about whom I’m writing today.

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.

Barry Hicks

Anaesthesia Medical Uncategorized

Cervical osteomyelitis in an infant

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.

So I think you see some of our problems.

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.

Several further films were taken – here is an example

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!