Surgical trauma Uncategorized

Diaphragm Injuries

Over the years I have seen a number of diaphragm injuries. Four come to mind as very interestingly different.

  1. 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.
  2. 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.
  3. 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.
  4. 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.

Being a surgeon is interesting!

Barry Hicks

burns Medical thyroid disease trauma Uncategorized

An expression of our daily life in Ethiopia.

For those of you who work exclusively in a hospital with everything, our hospital only had one X-ray box which was in the X-ray department – a long way from the ward. So our x-rays were viewed holding them up to a window. Bu if you look carefully you can see the cervical spine and a huge intrathoracic extension of a goitre.
And here you can see the specimen still in the neck but having been brought out of the superior mediastinum. In the late 90’s I wrote a paper on 300 thyroidectomies. The average weight was 500Gm. There were a lot more after that!
And a couple more above to let you judge the sizes!
The three pictures above are a series from a man who had been critically ill at home and left lying on his side. He recovered but was with a huge bedsore. Eventually he went home well. Often we had to take our grafts with a razor blade.
The next three are to show several more quite large areas. The last is an electrical burn. As you can see his arm has been amputated as was his leg. I am going through my slides and still have a long way to go but I have already over 100 slides of burns.

Barry Hicks

Medical Surgical trauma Uncategorized

Air in the wrong places

Quite an ‘airy experience.

subcutaneous emphysema (2) copy

tension pnuemothorax
in the pleural cavity

skull Xray
in the skull – we didn’t have a viewing box

in the abdomen

air in male genitals copy
in the male genitals

Barry Hicks

General Medical Surgical trauma Uncategorized

Alternative medicine


Working in Africa you were in competition with other forms of ‘medical practice’. There were witch doctors who sometimes caused us great difficulties. One case that I remember very clearly was a pregnant woman at term who presented in severe shock and bleeding heavily from a placenta praevia. After urgent resuscitation with IV saline as we waited for blood for transfusion her haemoglobin when checked was 3Gm/100mls, about 25% of normal. I have no idea of what her haemoglobin was before she started to bleed but suspect that it was low or she would have been dead. We were very short of blood and there was no blood bank in the area and, using the 2 units available, I quickly did a Caesarean. (She was nowhere nearly fully dilated.) The baby was dead. She survived.

As a first choice she had gone to the witch doctor who sacrificed a goat which she provided. He got the meat, she had to drink the blood to appease the evil spirit causing the problem! It hadn’t helped.

Then there were local healers. I have no doubt that they often did good. A high infant and maternal mortality in the country is a warning that a better system is necessary. But where I mostly met with their failure was in their treatment of fractures. Their major approach was to use external fixation with strips of bamboo tied together very tightly with string. They didn’t have Xrays; they didn’t understand the practice of fixing the joints above and below; they didn’t know how to assess the potential excessive tightness of their fixation with possible nerve, vascular and necrotic problems. They surprisingly didn’t seem to have learned that fractures swell in the early stage of the healing process. We have been ingrained with the 5P principle, watch for – Pain, Pallor, Pulses, Paraesthesia, Paralysis. They do not understand this. They didn’t understand early mobilisation. Therefore we faced initially necrosis with gangrene +/- infection. Then stumps where the limb had dropped off, contracted joints, extreme sepsis etc.

Amputations performed, because of infections, usually had to be of the guillotine type with refashioning when the situation was better controlled. Occasionally on examination of the amputated dead limb we could not find evidence of a fracture. I will show you a few as they presented.  Some of the pictures are a bit nasty. It was rare not to have one or more in the ward every week.

lumbar colostomy Medical Surgical trauma Uncategorized

3 paediatric spontaneous lumbar colostomies

I have seen a ‘spontaneous’  colostomy in a strangulated hernia which presented after days of pain. But even more unusual, shortly after that I had 3 cases of lumbar colostomies in children. One was in a boy who fell onto a sharp stick which went into his right lumbar area. Faeces began to discharge immediately but he lived hours away in an area without roads and his parents were very poor. He lived and after 3 months they had enough money to travel to our hospital. By that time he had developed a huge ulcer as seen in the photo below.

Medical Surgical thyroid disease trauma Uncategorized

Thyroids in all shapes and sizes

Some 25 years ago I wrote an article for presentation at the Ethiopian Medical Association meeting in Addis Ababa. I presented 300 cases of which the average weight was 500Gm. The incidence reported by the pathologist of cancer was 15%. The majority of malignant areas were very small and nothing further was done for those cases. In the following 25 years I saw many more.

male large goitre
This man’s specimen weighed in at 2kg. The depigmented area was due to previously applied local herbs, which didn’t cure the condition but had caused a lot of fibrosis down to the thyroid gland itself, increasing the difficulty in what is usually an easy plane of dissection.

burns Medical Surgical trauma Uncategorized


After I had recovered from the illness which brought me home from my first stint in Ethiopia, I became the on staff surgeon of a large (602 bed) Queensland country hospital. The previous surgeon had become the full time Medical Director. As I took over he requested that I allow him to manage the patients admitted with burns. I was only too happy to agree. I can hardly remember a single time in my stints in Ethiopia when we didn’t have at least one burns patient and usually more in the wards.

Burns are common in Ethiopia for the following reasons.

  • There are open unguarded fires in the middle of many huts.
  • Mothers often have to walk considerable distances to get wood or water. They go when the baby or infant is asleep and the children either roll or fall into the fire.
  • Most epilepsy is untreated and in an attack they may fall into a fire.
  • Mud houses, built around old timber, burn in a flash if they catch alight.
  • Electricity is frequently poorly installed.


Surgical trauma

Head Injuries

grad AM 17

Over the years the available investigations for head injuries has increased markedly . In 1962 my very first term as an intern placed me in both a general and a neurosurgical surgical roster. Sitting in bed 6 in bay 1 of the third floor general and neurosurgical ward was a young man who had broken his neck playing Australian Rules Football in High School. It had gone both unnoticed and untreated until he had begun to be paralysed. Before I came on the ward he had been operated on and the tracture fixed, but he was still unable to reach the tasty food which his family brought for him. I especially remember the grapes. I made a deal with him that every time I went past I’d give him some, provided that I got a share. We remained good friends until he died many years later. I assisted in some neurosurgical procedures at that time  but never got to do one.