Warning: This post contains graphic medical images.
This week started with an orientation to the hospital. I learned where the theatres were, where the clinic patients were and the location of the wards. Patients were housed in common sleeping rooms with 4 – 20 patients per ward, with men and women housed separately. I was introduced to Dr. Irungu, the Kenyan consultant whose service I would join.
I quickly realized here that the practice of general surgery is far broader than what I am used to. One of the first cases I scrubbed into was a transcystic suprapubic prostatectomy. This is a case that is seldom performed in the US but is frequently done here. This man had disabling enlargement of his prostate that had resulted in urinary retention and renal failure with a creatinine of nearly 4. His renal failure resolved after the placement of a foley catheter and monitoring for several weeks. After confirming by biopsy that the prostate was not enlarged due to cancer we removed his prostate by this transabdominal procedure. He was extremely thankful when we discharged him four days later sans catheter and urinating on his own. This basic surgery had transformed his life and reversed the process that had resulted in his renal failure.
I encountered a disturbing patient early in my second week. During clinic we see about 80 to 100 patients between two consultants and two residents. I met and admitted a young man from a large refugee camp. He had initially had a “leg blister” two weeks prior. When I met him he had at least 15% body surface area total skin loss to his left leg. It was a lesson in muscular anatomy, as all the muscles were completely in view. The joint capsule was open, seeping a mixture of pus and synovial fluid. He had had a debridement procedure elsewhere, but it had been wholly inadequate. Although not in critical condition or septic shock, he would need extensive debridement and at least an above knee amputation if not a disarticulation of the entire leg. Regardless, he would require weeks to months of rehab even given an expeditious amputation with skin closure. We took him to the theater the next day, and our fears were confirmed. There was extensive soft tissue loss with residual deep infection. He would require leg disarticulation.
The man refused to consider amputation, stating that he was young, needed to work, and could not do without his leg. He and his friends demanded discharge so that they could go to look for another surgeon who would be able to save his leg. Reluctantly we released them, telling them we were more than willing to help them if they wanted to return. The needs are large, the presentation was late, and the die was cast. I hoped that this was not the last that we would see from him, because I am sure he would progress to generalized sepsis and death without amputation.