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.

Onc(hocerciasis)ology

When reorganising, de-cob webbing and cleaning the hospital library I pointed to one of the newly labelled sections on cancer and asked one of the first year nursing students, who was helping us, if he knew the meaning of the word “oncology”. Although obviously unsure, to his credit, he gave it some logical thought and said “is it the medical speciality that deals with onchocerciasis?’ (River blindness). Whilst river blindness (a parasitic worm disease transmitted through the bite of black flies)remains endemic in many parts of West Africa, cancer appears something that has little presence both in and out of the hospital. Whilst having the potential to affect anyone, cancer is predominantly a disease of older people and the life expectancy of 48 years in Sierra Leone undoubtedly limits the target age group for many forms of malignancy. Even for those unfortunate enough to be afflicted by the disease, without the facilities of CT scans and laboratories equipped to comprehensively examine tissue biopsies, a definitive diagnosis often remains elusive.

Unlike the valuable “2 week rule” in the UK that ensures patients with a suspected cancer are seen by a specialist within 2 weeks, even a presumptive diagnosis here can take many months. A recent female patient had a ‘mass’ removed from her womb 6 months ago and was told it was probably a cyst or fibroid (benign tumour). She has since attended twice with severe infections, anaemia requiring blood transfusions and a recurrence of her mass. She was referred to Kenema (the nearest government hospital) who subsequently sent her to Freetown. Even without a full set of investigations, her prognosis is questionable.  Without undermining the severity of her illness, sadly, in contrast to other patients who may find themselves in a similar position, she is comparatively fortunate in that her husband has the available finances to be able to take her to Freetown for treatment and pay for hospital bills. A significant proportion of patients I see appear to struggle finding enough money to meet their basic nutritional needs and the uncomfortable reality of having to alter prescribed drug treatment to fit with what money the patient has is a daily occurrence; investigation and treatment in Freetown remains a matter of fantasy for most.

In spite of this, the vocabulary and associated fear of cancer has, to some extent, penetrated even the most rural areas here. I saw a middle-aged (in UK terms, not Sierra Leonean) woman with a hard craggy mass in her breast that she had been observing grow over the last year at home in her village. When we discussed the possible causes of the lump, it was her who volunteered the word tumour and then broke down in tears after I agreed that this was a possibility. I saw her a few weeks later after she returned from Kenema saying that she didn’t have the money to pay for her scan or treatment.

Although, there are perhaps few similarities in the practice of oncology between the UK and Sierra Leone, one risk factor for the development of the disease which appears universally prevalent is alcohol. Not that I wish to do my dear friend Victor (the bar owner) a disservice, for better and for worse alcohol is rooted in daily life and with a 50ml sachet of 43% proof alcohol costing only 500 Leones (around 8 pence) alcoholism is regrettably within reach of even the poorest Sierra Leoneans.  

I hasten to add that our trips to Victor’s bar have become slightly less regular, but this in part due to the frequent evening downpours that dissuade us from venturing down the muddy road. Even if we do squeeze in a drink, we always appear to be trapped in a game of chicken with an impending mass of charcoal grey clouds that ominously approaches us over the ridge at the top of the village, often just as the lids are removed from bottles. The knowledge that you will have to race against the onslaught of a heavy thunderstorm does not make for a particularly relaxing drinking experience!  Although we should be heading towards the ‘dry’ season, the humidity doesn’t appear to be letting up. Even when the rain isn’t torrential there is often a fine mizzle that appears to descend from the skies to the level of your face but be absorbed into the hot dusty air before it has a chance to reach the ground. (How very British, a few months in and we’re back to talking about the weather…)

Incidentally, on the first day of reopening the library we only had one student come in to browse the available literary selection. As in all things, behaviour change takes time. When I was here in 2010 a significant proportion of free malaria nets that were distributed were used to catch fish as people thought this was a more productive use for them. Three years on, thankfully through education, more people use them to sleep under. Hopefully we will increase the library use with time by promoting the benefits of reading.  Thankfully tonight I have just returned from a heartening few hours with a library full of students.

 

Update on Evelyn: When I ventured down one evening to collect her empty pots I was saddened to see her bed empty and the pots stacked neatly on the neighbouring bed. Fortunately one of her fellow TB patients explained to me that she had got fed up of waiting for her TB drugs, supplies of which ran out 10 days ago and decided to venture back to her village to see her family. Frustratingly there is a national problem with the supply of TB drugs in Sierra Leone and daily calls to the district TB coordinator have thus far proved fruitless. Whilst I am thankful that Evelyn now has the strength to travel to see her children, partially treated TB will most probably recur and may be more difficult to manage due to problems with the increasing resistance to drugs.  We have sent word to her village and hope she will return to the hospital soon.

Update on Tomatoes: Doing well. Watering was a problem last week as we were both scared by a fist-sized hairy spider trapped with between the pots in the gap between the shutters and the window but thankfully the creature (George) has now departed. We are exploring the options for planting out but the choices for ‘grow bags’ are a bit limited!