The surgical team arrives

The surgical team have now been in Addis for a week and the first of our patients are beginning to come back to our Cheshire home, typically with a swollen face and a fragile sense of humour. On Tuesday I was in theatre getting a sense of what our surgeons do. I was with Ayesha, a 15 year old girl who has a large noma defect on the left side of her face, and a jaw clamped shut. The extra bone that was formed between the facial bones was removed and the jaw released. This was overseen by the most brutish of the lot, the ENT surgeon, with a hammer and chisel. It’s a different experience watching this when you’ve had three weeks to get to know the patient.. This discomforting feeling was balanced with a sense of elation around the theatre as the mouth was opened, for the first time since Ayesha was a small child.

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The plastic surgeon then started work on the right forearm. A large flap of skin was dissected, as was the large radial artery, with a few of the muscle tendons that would be used later. The flap was then lifted off of the arm and put over the hole that was left in her face. Meanwhile the maxillo-facial surgeon had been dissecting the neck to expose the carotid artery and jugular vein. The artery and vein from the forearm flap were then threaded from the face and down into the neck. Then the microscope is brought out for the fiddly bit. The radial artery of the flap was sewn onto one of the arteries in the neck to give the new flap a blood supply (the superior thyroid artery in this case) and the vein of the flap was plugged into the vein of the neck so blood from the flap can drain. The needles the surgeons use are almost invisible to the naked eye, the calibre of the vessels being just a millimetre or two. The clamps were released and we all watched to see the flap come alive. A carpentry-like tool is used to raise a skin graft from the thigh to cover the donor site on the forearm. She will inevitably be left with a large scar here. Everyone got sewing again and the 9 hour operation was complete. However the healing is just beginning and the next few days are essential. Not all free flaps like this will survive.

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Dissecting the radial forearm flap

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The flap is mobilised and ready to be grafted to the face

Ayesha was an excellent candidate for surgery. She is young and will benefit a great deal from the functional and cosmetic improvement. However this week we said goodbye to some of our friends. Due to various reasons it was not appropriate for them to undergo a major operation.

GOODBYES

Kadyash is probably about 40 years old. Out of all of our patients she probably has the worst facial disfigurement cosmetically. Her face is dominated by protruding gums and teeth. She doesn’t have a nose and the left eye socket is destroyed. The outer third of her tongue has dried and keratinised and acts as her lower lip when she eats and talks. What is naturally surprising to us all is that she has three children, as does another patient with a large disfigurement about whom I have written before. As I examine the rest of her body I discover her heart is beating hard in her chest, and she complains of some chest pain when she walks too far. Her blood pressure is slightly raised so I order an ECG and she indeed has heart disease secondary to untreated blood pressure. This is an increasingly common cause of death in adults from the age of 40 in sub-Saharan Africa. It’s unclear whether she is fit for a large operation. Back at home she would have more cardiac investigations, but out here we can’t trust the investigations that are done. I sit down with her and have a long conversation, long for two reasons 1) because there’s lots to talk about and 2) because we have to go through two translators. She has come a long way, a three day journey from South Sudan, and has got her hopes up for an operation that will change the course of her life. Instead of telling her she cannot have an operation I give her the information that will let her make the decision by herself (this is a form of manipulation that doctors use on you every day). Although we would have loved to have helped with her appearance there was a risk of orphaning her three children. Once this was made clear it was a no brainer for her. Although she does indeed have a large facial defect that is amenable to surgery, she has lived with it all her life, learnt how to talk and eat, and completed important life goals such as having children. Unfortunately there is no room for cardiac follow up after her discharge. Her heart condition will deteriorate over the next 10 years, but she would have lived to the average life expectancy for rural South Sudan, and produced three children. There are times to interfere in the natural course of people’s lives, and there are times to keep clear. When importing high-tech surgical services such as these, it is essential not to abuse the temptation to do too much. Kadyash is an amazing woman. Although I’ll never get my head round the life she has lived, we’ll never forget her bashful smile.

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Julia and I saying farewell to Kady

Chot is about 30 years old and also from South Sudan. He came along with most of his upper lip destroyed, but good maintenance of jaw function. He was due to have an operation on Tuesday. The surgical team had planned to use part of his bottom lip and move it round to make a top lip. Before arriving at the hospital I had been informed he had refused to sign his consent and I was going to talk to him to find out why. Unfortunately on arrival I was asked by one of the management team to ‘work my magic’ and ‘persuade him to have the operation.’ The other two cases in that specific theatre had been postponed that day and there was apprehension about a potentially empty list. I went to talk to Chot, who was in a state of terror. It seemed that the shift from rural Africa to a private hospital had been a bit much. As we talked I found out the reason for his refusal. He said that although he wanted a new top lip, God had made his bottom lip perfectly, and it was not his right to undo God’s good work. This wasn’t meant flippantly, he meant it absolutely. This man’s religious beliefs had not been taken into consideration. Fortunately he was allowed to make an informed choice. He left the next day for the long journey home, disappointed, but having been allowed to make the choice that was right for him, and importantly, not us.

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Some of our patients help loading up the surgical equipment

Agino is a 24 year old lady from Bahir Dar, 10 hours north of Addis. She has had a large soft tumour growing on her face for the last 5 years. She covers her face at all times in public. She has an unusual case of venous malformation, the tumour made up of veins full of blood. Her relationship with her face is a little different from our other patients. She has grown up with a normal looking face, her fortunes changing having reached adulthood. Adversity and stigmatisation are not things she has grown up with but are new players in her life. Unfortunately our surgeons here are not able to operate on this condition. The risk of bleeding in this environment is too dangerous. The preferred treatment is ‘sclerotherapy’, injecting a caustic agent into the feeding veins to close them up. It’s a pretty specialist procedure carried out usually by interventional radiologists. It appears that there is no service available here in Ethiopia. So what do you do when a lady like this comes under your care? What I have done is probably a little naive. I promised this lady that I would find a way of helping her, before doing the research as to what it may involve. It’s not the first time someone has got carried away in a consultation, but it’s done now. This lady will probably need to travel abroad for private treatment in a specialist centre and she doesn’t have any money. So this is your first warning for a future fundraising campaign. Hopefully by exposing my promise I will be further motivated to make it happen, such is the power of accountability. If you know any interventional radiologists, get in touch! She is happy for me to use her photographs to appeal on her behalf.

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Now I know for a fact that some of you grudgingly wade through the medical stories to eventually get to all the latest birding news. Some of you are open about your passion, some of you remain securely in the closet. However I must tell you that bloggers get a lot of stats about their page and I can tell exactly how long each of you stares at the birding section. I know who you are. Here’s a few shots to get you through the week. Get ready for a bumper edition next week as we review the construction of a new bird table!

With a tail length that Chaucer would be proud of, it's the speckled mousebird!

With a tail length that Chaucer would be proud of, it’s the speckled mousebird!

A Grivet monkey, closely related to the East African Vervet

A Grivet monkey, closely related to the East African Vervet

Menelik's busbuck, this time the female

Menelik’s busbuck, this time the female

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Three common waxbills sitting in an Acacia tree

Out and about in the rural highlands

Out and about in the rural highlands

A human boy

A human boy

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