08. Imperfect Instruments

08. Imperfect Instruments
11th August 2013

In the small hours of the morning of Thursday 8^th August 2013, I saw what I expect will be my last womb, (barring, perhaps, when I am finally put into Fort Semolina Retirement Home, getting allocated the bath chair opposite a naturalist with procedentia).

It was a blessing that my last ever action as a doctor was an operation; and that my last ever operation was assisting a caesarean. Like the seasoned night-club bouncer on the door of The Wonky Innards, I have grappled far too often with unwelcome visitors, bustling them to the abdominal door, and thence into the hands of the waiting pathologist. How much nicer to find that the ruckus was due to a little baby crying with joy at the prospect, finally, of meeting the outside of his mum.

A wriggly boy, who had struggled to be born in a long labour, responded heart-warmingly to being vigorously dried and wrapped, and thereafter greeted his weary mother with one of life’s most beautiful sounds. Welcome to the world, little baby.

Hizza was the surgeon, and it was to be our last operation together. The operation was performed, as always in Berega, with imperfect instruments – needle-holders that, in an irony lost on them, no longer hold needles; old-fashioned sutures; torn drapes; gowns with one cuff missing; over-tolerant scissors that only cut after three final warnings; a catheter the size of a hose. The surface on which the game was played, instead of being softly-surfaced memory-foam, was an ancient, hard table, rudely covered with an even more ancient rubber sheet. Nevertheless, Hizza made a good fist of it. He did a horizontal incision instead of his previous vertical; he remembered to make a double-bite stay on each angle; to leave these knot-ends on a clip; and all traces of Cornish-pasty-ness had been eliminated from a precisely-executed double-layer closure of the uterus. Nice job.

I am sure that he will not mind if I say that not long ago, he also was an imperfect instrument; the product of his circumstances. He had had sparse, if any, one-to-one supervision in his surgical training, and what he knew was what he had gleaned and inferred. His eagerness to entice every last tip and nuance of surgery out of me before my final day, was touching and humbling. I felt that if he in his life now performs as many thousand caesareans as have I, then it will truly have been my privilege to have been there for him; there in his early days. This alone was worth crossing a few continents for.

Of course, he is not yet perfect. The fact that perfection is an unattainable goal means that both he and I will always be imperfect instruments. (Although I am surgically less imperfect now than at my first abdominal operation in 1976. It was an appendicectomy. I remember it vividly, not just because it was my first; nor because it took so long that I could barely remember life before it began; nor due to the resultant stress perhaps being the origin of the challenge to my scalp which has blighted my barber’s life ever since, and is perhaps the reason why surgeons wear hats; but principally because in those days you learned by watching rather than by being taught. (As Hizza did.) And so when I asked if I could do this appendix, the senior registrar said, “Have you done one before?” “No.” “OK. Well you can do this one, but I’ll wait in the coffee room so that I don’t put you off”. True story.)

Since then, I got better, but never perfect. There must be a book or two in there, (or more probably already out there, as are most of the stories that I otherwise would have written), on the paradox that purposefulness is the pursuit of the unattainable, and futility is the taking of your foot from the path.

It is for the purpose of making doctors less imperfect that the new regulations of appraisal and revalidation are currently being implemented. I fully concur. When my revalidation date comes up soon, I will not have the evidence of 250 hours of ongoing education in the last five years; nor the organised reflections of patients and colleagues on my work; nor the five annual appraisals of my strengths, weaknesses, needs and plans; nor the plethora of filled-in forms. Apart from the last of these, the other elements are truly are good, and the day that I start to believe that my experience makes me exempt, is, (was), the day that I should retire. (The world is a better place because of Lord Lister, without whom many millions would have died of peri-operative sepsis. But if he were alive today, aged 186, I wouldn’t let him within twenty stretcher-poles of me if I were to need an op.)

And so, 41 years, 10 months and a few days after stepping up to Liverpool Medical School, eager and young and bursting with possibility and a strong liver, I now hand in my scalpel and exchange it for a pen – which, to be honest, is less likely to cut my hand.

The week that ended with a life-saving operation had begun with the tragic absence of one. Sion and I were on-call last weekend, and a twenty-three year old woman was brought in from afar with abdominal pain and collapse. White as death, she died in front of us, before we had a chance even to begin the search for a donor of blood. She might have had a ruptured spleen secondary to malaria, in which case she would have been difficult to save. But it was harrowing to think that it might have been as simple as a ruptured ectopic pregnancy, instantly curable by a simple operation, if we had seen her earlier.

The rest of the weekend brought many other challenges. Perhaps the most spectacular success was Sion’s clinical diagnosis of massive lung pathology in a child of eleven. Xray showed a complete white-out of the right side. Subsequent repeat pleural aspirations over the next few days, (tolerated with impressive and characteristic courage), eventually eliminated 1.3 litres of pus from the boy’s grateful pleural cavity. He is doing very well, but hides when Sion approaches.

During the weekend there were other deaths as well – one from cancer at one end of life, and one from meningitis at the other. But yet others were rescued by Sion, sometimes impossibly so – a baby with pneumonia whose oxygen levels were under 60% is now recovering well. (The mum’s comments will be one for the appraisal folder.) (I hope that this still counts under ‘Annexe 4B: Comments from Patients’, even though it is from the mother. You could imagine that sometimes maternal comments are inadmissible, like when I gave my ‘Annexe 4C: 360-degree Assessment – Comments from Colleagues Form’ to my mum. We came from a collegiate family, was my argument.)

Anyway, Sion - you made a difference. Not to the totality of suffering in the world, but to its sum.

Regular blog-readers will know that I like to ooze effortlessly from paragraph to paragraph, forging unlikely links with literary dexterity. And so it is with suction cup extraction.

I brought Kiwi suction cups to Africa, wondering whether the twenty that Nicholas nobly fast-ferried from Cardiff would be enough. As it was, I only used four in two months, during which time I performed or assisted at 70 caesareans for obstructed labour. Their use in these cases still emphasised their irreplaceable importance in Berega-like settings, but I am perplexed by the rarity of need there. I brought forceps, but did not use them once. Furthermore, I did not see a single case of PPH, (post-partum haemorrhage), the world’s number one killer of mothers. By contrast, first-stage obstructed labour was a daily occurrence. I shall annexe a page of musings on this for the childbirth professionals and the curious.

I can talk with despot-like confidence of annexing, because I am writing this from Dar-es-Salaam. Not only does my computer now say that I have internet, but, much more importantly, it also behaves as if I do. (Note for future African Internet providers: one out of two, though technically a pass-mark, is simply not enough.) Soon you will be able to see our house, the hospital, and the environs, through the inestimable wonders of You-Tube and the World-Wide Web.

One of the joys of the net, besides being able to read my emails more than one word at a time, is that I have finally been able to check out Kofia! (Google Kofia + Berega if you don’t know it.) Blanché, Debbie, and the worthies of Guildford, I salute you!! Starting with just good will, knitting needles, and a wireless router, you have begun a process which has the potential to enhance the outcomes of childbirth for people who have never known anything other than fate. Just the babies’ hats would be a wonderful and welcome intervention. Getting cold is the biggest threat to a baby struggling to adapt to its first few minutes outside the womb. Berega cannot afford proper baby towels, and the knitted hats will send a message of loving warmth from one world to another.

More importantly still, (no pressure!), I am hoping that Kofia can be a powerful instrument helping us to begin to reach out to those current beyond access. On my last day at the hospital, the key players met, and we have a plan for the first year of outreach to the community. I will write a separate page, with the details and map, with photos, and with links to a video of the road that leads there. Working alongside Hands4Africa and their plans for community development and transport, I believe that we have a real chance of starting something inexorably important. We will begin cautiously, and take each step gingerly. We will seek first to understand. We will try to measure. The purpose is not to do things to people, but to create harmony of purpose. Synergising the efforts will be slow. Traditional Birth Attendants making a hard-won and inadequate living from bringing the next generation into the world, need to be our local partners, and that will take time. However, I won’t listen, and nor should you, if Caution wheedles: “Don’t start! Go back! Relax! The distance isn’t going to look at itself, you know!”

A journey, once begun, will always lead to somewhere more interesting than your front room.

Nowhere was this more true than my last journey from Berega. (A better link this time?) Leaving the hospital after two months was strange.  We set off at 6.30, just in time to see the new moon rise for Eid. (I can only hope that the joy with which it was greeted will encourage a more regular attendance in future.) For a while at least, I had my last powdered milk cup of tea. Our last banana breakfast. The last “News of the morning?” greeting to the gateman, (the answer to which is always “Good!”, even if one of the Four Horsemen of the Apocalypse had stabled at your home the night before). My last time to hear “Shikamoo!”, (a greeting of respect to elders), from children on the long walk to school. No more caesareans at which the mother calls her child after me, (even if she spelt it ‘Rollent’).

I have four more days in Dar to finish putting things on the web, and to put on some of the lost two stone, (assuming that the current population of protozoa in my intestines can be eliminated when the pharmacies open tomorrow). It feels unsettling to be unleashed back into the other world, but it is a very welcome unsettlement.

I will be continuing the work, and a pithier blog, for up to five years, (if I manage it. But if I stop writing it, you can stop reading it). Five years to see if the hopes and dreams for rural Tanzania can become more solid.

We have a good start. The meeting of senior staff and management with the leads of the clinical areas introduced to them the idea of agreed minimum standards of the hospital. I had anticipated a bloody battle, and a long, hard meeting. Well the meeting was certainly long, (and all in Swahili), but that was because the staff themselves punctuated every point with their own tales of how vital it was to build that standard into established practice. Rules are important in Tanzania, and lack of their being explicit has, it transpires, been unwelcome to many. The entire document got through with just a few additions, and no deletions. The uploaded draft is the final version. 

Berega has a charter.

A final reflection: You may have been surprised the first time that I discussed Berega Hospital’s flaws as well as its challenges? There is so much good in the hospital: sound lead clinicians, many dedicated and talented staff, and excellent managerial leadership. I myself wondered then, if it was acceptable to reflect on inadequate responses, and even to hint at what sometimes seemed too much like neglect. However, I decided that I needed to give you the story as it really is. However much better Berega is than it has been in the past; however much it is head-and-shoulders above many of the district hospitals in the rural areas; nevertheless it is true that bad outcomes in the hospital sometimes owed as much to its inadequacy as to its inaccessibility to those in distant communities.

Berega has been, like me, an imperfect instrument.

I hope you will continue to travel with us both as we seek the unattainable.

Laurence Wood

email.lozza@gmail.com

This is a post-script on the death of the young woman. For the faint-hearted, don’t read it. I add it because, more perhaps than anything else I have written, it evokes a picture of what needs to change in rural Tanzania.

The tragedy of the death of this young woman was shocking enough. But what illogically unnerved me more even than the death, was that the body was taken home by the grief-stricken family on a motor-bike, because that was all they could afford.