Lumps and bumps – its not all brain surgery mind!

Following a good time at the casino the weekend before last I thought I’d play Russian roulette with what specialty I’d end up working in today. So I wondered in to work and got soaked in the downpour. I could easily have stayed in bed and listened to the raindrops hammering against the tin roof, but alas duty called! 

Raining!

Anyway as I walked towards theatres one of the trainees who was leaving after the night shift of the weekend informed me of the desperately sad news that a lady that I had been a part of looking after had passed away on the intensive care unit overnight. Sadder still, as she came to hospital in labour with her first child. Amongst the emergency casearian section for shoulder dystocia the baby didn’t make it. She bled and was stabilized with a hyseterectomy and moved to the intensive care unit only to bleed for the second time the following day (when I got involved in the case) and did remarkably well until last night when her kidneys that had been failing stopped working over the weekend and her lungs filled with fluid and she eventually passed away. Tremendously sad story and leaves a husband and family bereft. Incredibly sad and frustrating that this continues to happen despite all the courses and the advancement of medicine here.  But it makes working here all the more important. So that shook off my Monday apathy and I strode purposefully to theatre.

  When I got to main theatres it was a pleasant surprise that there were a few hands on deck so to speak. And the ship seemed to be sailing in the right direction for once! So whilst looking around at who was where and what was going on I happened across a few interesting cases. Now to many medics in the UK – when one mentions that one is going to do a ‘lumps and bumps’ list – it generally means a few little excisions of cysts, lipoma’s or abscesses or sometimes even a hernia is counted in this. Basically small fry operations (not to the patient or surgeon of course).

 

However here, lumps and bumps take on a whole new meaning! And not just any type of lumps and bumps – but neurosurgical (brain surgery!) lumps and bumps.

We started with a patient who had some of the largest collections of lumps I have ever seen. They had a condition called von Recklinghausen’s or Neurofibromatosis. These cause loads of lumps and brown skin stains (café au lait patches) all over the skin. This patient has a textbook entry of them all over her body but had come as there was the largest neurofibroma lump I have ever witnessed covering her hip and thigh. So large that she had trouble doing up her Chitengi (which is not unlike a sarong skirt) – which was the reason she presented for surgery. However this passed without too much of a hitch and she will soon be able to go about her normal business wearing her normal clothing.

Cafe au lait spot and a neurofibromatosis on back of knee

The second had two of the largest bumps I have ever seen growing out of a skull. To begin with we thought they were just fatty tissue under the skin lipoma) but on looking at the x-ray we could see that they’d eroded through some of the skull. In fact the neurosurgeon decided to do what the red Indians did – a scalping in order to get at them easier (under anaesthetic of course!). Anyway it turns out that these were not lipomas or cysts but they decided that they were secondary metastatic cancer spread from somewhere else as they extended into the skull. I have my doubts that this is the correct diagnosis but then again these are the first lot of these bumps that I have ever witnessed so it may well be true…. I hope to find out before I leave!

2 large bumps

 So having warmed up nicely (well actually with the new aircon blasting down on us it was rather cold) the surgeons decided to press ahead with the first patient on the list. A brain tumour. A meningioma to be precise and a very large one at that in a chap that is a year younger than myself (yes that does make him 20! Ahem!). The scan is remarkable for two reasons – firstly its size and they are operating with no clever technology (stealth) but also that it is an MRI scan not a CT. Now anybody who’s a part of the NHS or even had a scan knows how long they had to wait to get a CT scan let alone an MRI scan – so how on earth have we got them for a brain tumour…. Well, it seems when the CT scanner in the main university hospital in Zambia hasn’t worked for about 4 years, and the back up CT scanner across the car park at the Cancer diseases hospital has also stopped working as of 3 months and the Military hospital cannot deal with the now increased influx of CT scans (even being taken from our ICU in an ‘ambulance’ – well a van with a cylinder or oxygen in the back) then all these cases will get an MRI scan at the cancer disease hospital instead (the MRI in UTH is of course… out of action!)

Massive meningioma 

Anyway at 12.30 a craniotomy for meningioma (basically taking the skull off to shell out the tumor) is not what you want to hear, bearing in mind that the standard operating times in Zambia is until 13.30…. It was going to be a long one…. It was also going to clash with the afternoon critical incidents meeting and teaching session that we’d organized. However there was a need to do the case and so we proceeded.

 We started off with the pleasing aspect of getting everybody in theatre doing the WHO Surgical Safety Checklist as led by one of the anaesthetic trainees. This is to prevent operating on the wrong person/site or missing vital information such as allergies or problems and also encourages good communication and teamwork. It isn’t used well everywhere but the neurosurgeons are one of the better surgical disciplines at doing it.

Mmed trainee leading WHO Checklist

 Then the surgeons buried themselves in their work and I dashed out to the ‘canteen’ to get food. I usually take in a packed lunch but this morning in my lazy state I decided I’d not bother. Whilst standing in a long queue to pay for some food I then recalled why I usually bring my own. Nevertheless I got to the front only to be told I had stood in the wrong queue and this one was for doughnuts and scones. So I decamped to the other one where I paid for my Chicken and rice (not brave enough to have caterpillars in the hospital – have tried at a restaurant previously!). Anyway 20 minutes later as I get to the front of this queue there is nearly a revolt as they run out of chicken ...Seriously, the only thing that could have been worse would have been the news of no more Nshima – so furious were the crowd! Thankfully thought it was a misunderstanding and they just required re-stocking of the chicken and order was restored!

 I get back to theatre and think its odd as my colleague Papari and Dave were both missing. It turns out that whilst I was desperately trying to secure some lunch they were desperately trying to resuscitate an emergency on intensive care (which is next to the main theatres). Turns out it was my trauma patient from a week ago (the one with a fractured pelvis and no chest x-ray who later turned out to have a fractured neck, fractured ribs and haemopneumothorax blood and air outside his lung), fractured lumbar spine and pelvis). He had also developed kidney failure from rhabdomyolysis (muscle breakdown) over the weekend. He also sadly didn’t make it despite their best efforts. Sadly another frustratingly young death to be involved with.

DIY Drill

Hand saw / cheese wire drill

  By the time I got back and look closer at what the surgeons were doing it seems that they hadn’t actually removed the skull at this point in time. It seemed inordinately long to me but the flip side was that the blood loss was very minimal (just as well as we only had 2 units of blood available anyway!) They then broke out the ‘brain drill’. This sounds like some serious piece of kit. It is sadly however a basic Black and Decker drill (a la what you use on a Bank Holiday Monday to hang pictures on the wall!) wrapped in a sterile drape. Thankfully today the batteries were charged and it made the requisite 5 holes it needed. They then painstakingly hand saw the bones between the drill holes to remove the bone flap.  This was interesting to watch at least as it was something that I could actually see and not just the constant digging around in the head that continued for the next 4 hours after this!

2 anaesthetic charts stuck together is a sign of a long operation!

  They got as much tumour as they could out. At some stage one of the porters arrived with quite a few polystyrene boxes of chicken and chips and a bright orange (teeth dissolvingly sweet) fizzy drink called Miranda. Apparently if the staffs stay past 13.00 then the surgeon/hospital is bound to provide them with lunch. So credit where credits due the surgeon did look after his staff – thought the poor scrub nurse’s one was stone cold by the time the operation finished! It also meant I could have avoided the hour of my life at the canteen queue system! Every day’s a school day I guess!

 Anyway after a painful/painstaking (depends on whether you are looking from an anaesthetic or surgical perspective!) 6 and a half hours they decided they’d got as much tumour out as they could today. On further clarification I was told that they weren’t going to get the rest and anyway it would grow back in due course!!! 6.5hours later!!!! So we took him over to ICU where we woke him up and he’s ok if not a little groggy after all that Halothane! I am crossing every fibre in my body that this remains the case overnight, as my current ICU statistics are looking a little grim. Though not as bad as the realisation that my own oxygen saturations are way lower than the patients - even on ICU at times! Well.... it was a long case, I had to find something to do!!