Surgery at Kalene

I thought I would give a summary of the surgical work I’ve been involved with since our arrival at Kalene.

The medical director at Kalene, John Woodfield, is a general (colorectal) surgeon who is from New Zealand and trained in the UK. There is an orthopaedic surgeon, Peter Gill, who alternates working at Kalene and in Sunderland, UK on a three month basis.

We have two general elective operating days and one elective orthopaedic day and then plenty of emergencies in between.

There are many challenges in surgery here in rural Zambia. The first is decision making. It is quite easy to do more harm than good and in making therapeutic decisions, we are often trying to decide whether it might be better to do nothing rather than undertake major operations in a resource deplete setting.

Investigations are limited. We have a laboratory which can give a blood count, type and match blood, perform limited microscopy and gram stain, ESR and HIV testing.

There is a basic ultrasound machine, so I’ve rapidly taught myself some rudimentary skills (at least there is no pesky radiologist to decline all the scan requests!)

We have a fairly unique arrangement for histology. Very few rural hospitals in Africa have access to any pathological labs. Kalene has a historical arrangement (a result of a memorable student elective) with a very generous hospital in Glasgow, UK. We can send (small) tissue samples and just six weeks (or so) later we get an emailed histology report.

There is x-ray but we are frequently out of film and it is only available during office hours. There are lots of other shortages. We are often low on blood to transfuse and there are frantic searches for donors amongst staff or relatives. We recently had a drought of IV fluid - you have to prioritise who needs that last bag of saline the most. One becomes fairly stingy with every material. It’s surprising how far you can make one stitch go.

Nobody comes to this type of surgical environment expecting the best equipment but it is definitely a steep learning curve getting used to the limitations. Blunt blades, poor light, confined space, suction that doesn’t suck and gloves that fall apart before you’ve even put them on are all challenges that you gradually adapt to. There’s recently been a shortage of surgical swabs – trying to do a major laparotomy with just a few tatty 4 by 4’s, ringing them out and staring again was tricky! It is surprising though what equipment you can find here. We have endoscopy and can do OGD, flexible and rigid sigmoidoscopy, colonoscopy (if you can get the bowel prep to shift the kasava!) and flexible and rigid cystoscopy. There is a C-arm image intensifier which is useful for fracture manipulation and we recently used it with reasonable success for an on-table cholangiogram. There is a laparoscopic stack but no supply of carbon dioxide.

Elective theatre days are tiring. In addition to be being the surgeon, one is also the anaesthetist, ODA, ODP, scrub nurse and porter. This means (amongst other things) there is no break between cases and the day feels long. The sheer variety in a day’s list is impressive: going from a strange head or neck problem to a laparotomy, to a tubal ligation or three, to a couple of gastroscopies, to a nasty wound debridement with a caesarean section thrown in for good measure, guarantees to keep you on your toes. The heat in theatre adds to the challenge and the fluid and electrolyte losses of the surgeon are much greater than the patients’. But the theatre is surprisingly efficient – we can usually complete 15 cases during an elective day’s operating. There is a little transit time. The wards are about 20 metres from the theatre door and there is only minimal paperwork to slow the work down.

The patients are a challenge. They are all malnourished, all anaemic and about one in five have HIV. On the other hand, no one smokes and alcohol is beyond most patients’ means. It is a pleasure though to operate without a single gram of excess fat. There are some interesting geographical and cultural influences on operating here. Sigmoid volvulus is relatively common in young people in sub-Saharan Africa – probably due to anatomical variation and dietary differences. Saying that, the Lunda tribe seems somehow protected – I’ve seen only three cases in three months. Best management doesn’t seem to be clearly established: initial decompression with endoscopy/flatus tube or immediate operation and then whether to perform Hartmann’s procedure or resection and primary anastomosis. Sigmoidopexy doesn’t seem to be effective.

Amputation is seldom necessary – arterial disease is rare but occasionally required after trauma or infection. However, it has a much more profound effect than in a developed country. Rehab and physiotherapy are very limited, there is no social security and nearly all are subsistence farmers. Prosthesis are rarely available and wheelchairs very hard work on the local tracks.

Vasectomy is deeply resisted by men and open tubal ligation is nearly the most common elective operation, despite it being a bigger procedure.

Stomas are not well tolerated. This due in part to the difficulties faced by local people in learning to manage their appliances. Stoma equipment is in short supply. They are also culturally frowned upon more than in developed countries.

Trauma is common and the aetiology varied. Farming tool injuries, burns from cooking fires and falls from trees harvesting mango or caterpillars (depending on the season) and snake bite wounds. All wounds are dirty and managed relatively conservatively. Multiple or poly-trauma is thankfully unusual – a notable advantage of dirt roads is that it limits the speed of car and motorbike traffic. However, motorised vehicles are on the increase and boy racers also exist around Kalene – helmets, lights and seatbelts do not seem to be popular accessories!

The hospital is located close to both the Angolan and Congolese borders and about a fifth of the patients have travelled often hundreds of miles to cross the border to reach Kalene. So there are often complicated reasons why patients present late. It also means a lot of our work is picking up the pieces after surgical efforts elsewhere. Often we think we are working in difficult circumstances but hospitals and the surgical scene in Angola and Congo must be dire.

Medical ethics has a local spin that takes a little adjustment. Consent is an interesting concept. It is not always the patient themselves who is (culturally) expected to decide whether to undergo an operation. For tubal ligation for example, it is frequently the mother-in-law that has the final say! The differences in ethics can affect decision making. For example, with a significant rupture of the uterus, it seems more appropriate here to repair the injury and perform a tubal ligation. As I understand it, this is unethical in the UK and a hysterectomy would be performed.

Anaesthetics has been a learning curve for me. We do what is possible under local anaesthetic but frustratingly it is in short supply and relatively expensive. I’ve done about forty spinal anaesthetics. Ketamine is a very useful and plentiful drug! It can be used for analgesia, sedation and anaesthetic and is very safe. It is very unusual to have airway compromise, respiratory depression or hypotensive side effects which are common with other anaesthetic agents. Formal ‘full’ general anaesthetic with muscle relaxation and intubation is of course sometimes necessary, particularly with abdominal operations and this causes us all an extra level of stress!

Post operative care is interesting! There are no formal recovery/HDU/ITU areas and the most intensive monitoring we can provide is in Sister’s office. Analgesia is limited. We have paracetamol (oral only), brufen, diclofenac (PO + IM) and codeine. There is some pethidine but no morphine, not because of cost but limited by the wall of bureaucracy presented by the ministry of health to release it. I know the textbooks say pain thresholds are constant but I tell you, the Lunda are as hard as nails. You can give them a laparotomy from xyphisternum to pubis and they don’t flinch! The next day they are up and about on a bit of panadol and brufen (if they were lucky enough not to get skipped on the drug round by the student nurse). Enhanced recovery isn’t just encouraged at Kalene, it’s inevitable! I don’t think the ERAS protocols have guidelines for breastfeeding in the immediate post-operative period but it seemed to work quite well after one major laparotomy recently.

Here is a rough summary of my logbook for the last three months or so, to give you an idea of our work load:

1 right hemicolectomy (for ilea-caecal intusseption – presumed typhoid)
2 sigmoid colectomies
1 Hartmann’s
1 ileo-transverse bypass
1 gastroenterostomy
3 laparotomies for small bowel problems
1 laparotomy for SBO from pelvic abscess (PID)
8 inguinal hernias
3 paediatric inguinal hernias
2 open cholecystectomies (1 OTC)
17 OGDs
20 caesarean sections
9 ERPCs
25 tubal ligations
2 necrotising fasciitis
10 split skin grafts
And assisted with a few hysterectomies, thyroidectomies, the biggest bladder stone I’ve seen associated with a vesico-cutaneous fistula and a successful vesico-vaginal fistula repair.

I am very, very grateful for the support and encouragement from my supervisor and mentor, Mr. John Woodfield.