Aira Hospital

To lose a leg is catastrophic. There is no supply of prosthesis around and without a leg you cannot do the farming which is the only way to survive for 95% of the rural population.

It is an old dream of mine to be able to supply our amputees with an artificial leg. Readymade prosthesis in different sizes left and right are available and can be purchased from abroad if only we had the money. Made of out of plastic they need only some heating to be adjusted to an amputation stump. No need of high tech equipment or trained staff - only money is needed.

Recently during the Swedish election campaign the country’s infamous Marxist-feminist nr 1 burned 100 000 Swedish crowns in public to get the attention of the media. She got it with the same success as when she urinated on the red carpet among dignitaries during a gala in Stockholm. This time however she was sober.

In the same election campaign various car companies pay 8 million crowns for free champagne to everyone.

One of our patients made an artificial leg for himself. A bit clumsy, but it works.

Others do not have that capacity and therefore we always do our outmost to save a limb.

This unfortunate man was as drunk as the Swedish Marxist-feminist NR 1 when she urinated on the red carpet. He fell asleep outside his hut and woke up in the middle of the night as a hyena was having a good meal on his leg.

In the operating theater all dead muscles and other soft tissues were cut away and the wound cleaned thoroughly (wound debridement and revision).

Not much was left. However the anterior muscles kept the foot in (dorsal) extension so there is a substantial chance of getting the patient walking on two feet

After some days the large defect was covered with skin graft.

It looked promising on the latest picture.

The patients disappeared although he was told to return for follow up.

Maybe a lucky hyena got a full and undisturbed meal later?

100 000 Swedish Crowns would pay for 500 cesareans saving 1000 human lives.

The free champagne could keep Aira Hospital going for 100 years.

Priorities are indeed different in this world.

Only the surgeon who does not perform surgery has no complications.

Recently one patient was referred to Aira Hospital from a nearby hospital where he had been treated for a longer period. He had severe necrotizing fasciitis with a large infected wound. The tibia shaft was bare and indolent – probably already dead.

I have no doubt that the referring surgeon had done all his best to help the patient. When not successful he gave the patient a second chance by referring to us – an honorable gesture.

As I have stated before it is a tragedy here to lose a leg since there is no way of providing prosthesis for amputees. With only one leg farming is not possible. It is better to lose an arm.

Therefore we tried to save the leg even it looked rather hopeless. A bilateral bipedicular musculocutaneous flap (a muscle flap on both sides covered with skin and attached above and below) was mobilized and covered the bone nicely.

At first it looked promising.

But then alas! After a week it had necrotized as well and we were back to square one.

Both I and the patient then realized that an amputation was inevitable – an exarticulation through the knee joint was done. A fast and atraumatic way of removing the leg.

As mentioned before on this blog, cancer is a very common disease in Africa - contrary to common belief abroad. Patients tend to come late, often too late. Sometimes we are able to cure, but often at the cost of mutilating surgery. Very often patients will refuse an amputation and return home. Not infrequently they change their mind when the general condition is deteriorating due to widespread metastatic spread, but then it is too late to offer any treatment. Palliative treatment is not an option here.

One young lady agreed wisely to an amputation. The cancer (a soft tissue sarcoma) although large didn’t show any signs of spreading, so hopefully she is cured.

Since there is no way of providing the patients with prosthesis here, it is better to lose an arm than a leg. With one arm you can still walk around and cultivate the land, but with two crutches and one leg that doesn’t work. Not much of comfort for the young patient - but true  - and the only we could give.

This old lady presented with a Sarcoma Phylloides, a somewhat rare giant breast tumor which is not highly malignant but will recur if not removed radically. After excision of the tumor the skin could be closed with the help of local transposition flaps.

Our patients’ stoic acceptance of their fate never ends to impress me.

Some patients you never forget. The following story I have told before somewhere else. Those who already heard it please forgive me, but I always have those children on my mind.

One late evening there was the familiar knock on the door. The guard outside asked for my presence in the OPD (open patient department) for one emergency. The staff never calls me unnecessarily. Knowing that I am on call every day and night continuously, they always try to spare me.

In this case it was an older brother of a young girl who insisted that the doctor came to see her. The staff knowing very well that it was not an emergency case refused, but the boy was so persistent that finally they gave up and called for me.

The boy had come with his younger sister from a hospital some three hours by car from Aira. Before coming to Aira he had carried her several hours in his back to reach that hospital. But in vain - they could not help her. The couple was sitting outside that hospital not knowing what to do when a car passed by and asked if they would take the chance to go to Aira.

Now they were here and the boy wanted to know if we could help her. If not he would have to return with the same car in the same evening. That’s why he persisted on asking for the doctor to come and see her.

She had an enormous sarcoma (cancerous growth) of the right knee. She was anemic, but otherwise fit, and there seemed to be a reasonable chance to remove the malignant growth. So she stayed with her brother and was scheduled for the following day.

The right leg had to be amputated through the hip joint (exarticulation of the hip). A major procedure which turned out successfully since we could remove all the enlarged lymph nodes in the inguinal area.

On the round the following morning we found her smiling all over the face in spite of the disfiguring and painful surgery. “You removed my burden!” She exclaimed with great relief. “I never thought it would happen!”

Soon she started to ask for discharge. Why she was in such a hurry to go back home made us curious. She explained that there were orphanages. Both parent passed away some years ago, and they were living on the land they inherited after the parents. Her 16 year old brother was supporting herself and her two younger sisters by farming. She herself was keeping the house, preparing food and seeing to that her two younger sisters went to school every day. Now she was worried for the well being of the younger ones and wanted to return as soon as possible.

 The poor fund covered all the expenses including crutches and transportation back home. I never saw them again, but they are always in my mind. I wonder how they manage.

The person who took the couple back home told me that the brother tried to comfort his sister during the trip with the following comment “The good thing is, that in the future we need only to buy one shoe for you.”!

Merry Christmas! December 24 is not a holiday in Ethiopia. According to the calendar used in the country Christmas is January 7. So we had a normal working day, except that the program was very small, only 10 patients. But that was actually because we were not sure how we would end up with the autoclave which our clever electrician was working on the most of the day.

Miraculously he did manage to repair the equipment to my great joy – that was the best (and by the way the only) Christmas gift I had this year. It is really amazingly what he can accomplish with some very simple,old and partly defect instruments, and no formal education - he is a genius!

We marked the holiday by serving popcorn at coffee break in the operating room.

Even the X-ray machine started to work again after we had the third electric phase reconnected. Now it is only the ultrasound scanner which is still out of work. I had a look inside the scanner, but couldn’t find any loose cables or wires, so I am afraid that we have to bring the scanner to Addis Abeba – not very convenient for that sensitive equipment. I will have to work on it a little further before I give up.

Among the patients we had scheduled for today’s surgery was a small 11 years old boy with a staphyloma of the eye (completely destroyed and bulging eye due to infection). He was set up for an evisceration (removal of the eye ball). When the nurse put a needle in his arm as preparation for anesthesia he looked at the needle with his healthy eye and asked “and how is that going to help my eye?” We couldn’t help laughing.

The young women with the osteosarcoma of the arm who was strongly recommended to have a life saving amputation of the arm came back today. Her relatives brought her to the hospital for the operation, but when it was due, she had disappeared.

The staff had written on the card “patient totally refused surgery. Could not be convinced. → sent home” I am afraid that she will come back only when the cancer has spread beyond surgical cure, far too late to do anything for her.