To Cut or Not to Cut?

 
As Janna stood over me with a pair of old rusting surgical scissors, previously given to me by a colleague to practice surgical knot tying, I began to consider if, in fact, I really needed a hair cut at all.



The local barber shop

Although I have to confess I have let slip my previous routine of a daily shave before work, my hair was beginning to edge towards a somewhat Neanderthal appearance and I felt both patients and relatives may have a little more confidence in me if I had a trim. I first attempted to have a hair cut not long after we arrived and visited a barber’s shack at the top of the hill outside the hospital gates. The barber’s method of hair dressing was unorthodox to say the least. Instead of using clippers or scissors, he employed an interesting comb-like device into which he placed a razor blade which he used to make repeated small slicing movements hacking away at my hair. After around an hour of painful tugging and the constant feeling that perhaps he hadn’t quite understood what I meant by a ‘tidy up’ I emerged looking probably more dishevelled than I started. Having learnt from this experience, 2 months on I found myself in the Lebanese supermarket in Kenema looking at the two available hair clipper sets; a mains powered one or a slightly cheaper battery powered set.  Anyone that knows my frugal inclination and fondness for a bargain will be unsurprised to hear that I opted for the cheaper version. Predictably, this was the wrong call as when I got back to the hospital I discovered that instead of cutting, the battery powered clippers weakly pulled at the hairs as it glossed over them. And thus I found myself entrusting Janna with the scissors….

Of course in a hospital there are far more serious matters concerning the decision to cut or not. (Incidentally, I am not referring to the widespread practice of an initiation rite performed by secret societies that may affect up to 98% of Sierra Leonean girls and young women; the controversy and depth of secrecy of which means that it is probably appropriate that I only allude to it whilst I reside here).  I am indeed referring to the matter of operations and surgery, which can be a risky business even in the most high tech of healthcare facilities. In my first week here the surgical team performed an operation to the remove a very large football sized fibroid (benign tumour) from a woman. There was much fanfare surrounding this with a line of students queuing up to see the specimen and congratulatory talk of whether this was the biggest fibroid removed in Sierra Leone.  Conversely, there is little excitement or passion for the child slowly dying from preventable anaemia and malnutrition, and there were certainly no trumpets sounding out in celebration after 2 weeks of medical input managed to get a young man with suspected typhoid fever, pulmonary oedema (fluid on the lungs) and kidney failure, a potentially terminal situation, round the corner towards recovery.

Perhaps it is the physical and visceral nature of surgery and operations that maintains the palpable awe that surrounds them and their ability to allow people, whether medical or not, to relate to a visual understanding of the cure of an illness which is seducing. However, one of the most important lessons in any surgical speciality maybe knowing when not to cut; just because something can be done does not mean it should be. Whilst I hope the woman who had the fibroid removed made an informed decision about the possible risks and benefits before choosing to proceed, I imagine there would have been far less back-slapping had a complication arisen, even one requiring relatively simple correctable measures such as oxygen which is not available.

Another increasingly difficult surgical decision concerns whether to carry out a caesarean for a woman in labour. On UK delivery suites there is naturally a relatively low threshold to intervene if there is any suggestion of foetal compromise. However, in rural Sierra Leone, even when accounting for the limitations in how the foetal heart can be monitored, the boundaries are rather different. Subjecting a woman, particularly in her first pregnancy to a caesarean will leave her with a scarred uterus that may well have to endure labour five, six or ten more times, which possibly will occur nowhere near a health facility or near someone trained appropriately to deal with the complications that may arise including rupture of the scar. In addition, the initial operation will have an increased risk of complications due to the very nature of the environment of limited medical resources and expertise that it is taking place in. The consequence of this heightened risk to the mother’s health and life, both in the acute situation and for future pregnancies is that the value placed on trying to save the life of her unborn child through surgical intervention is sadly less than it should have to be.  

Thankfully I have not had too many comments on my new look. At least the difference between a bad haircut and a good hair cut is only 2 weeks; the consequences of an inappropriate operation can be lifelong.