A striking "Natal" experience

A Natal experience The strike was a day old. I woke up wondering what the day would hold. I was not concerned about the principles of the strike. They were sound. Physically deteriorating hospitals such as King Edward VIII have been unfit for habitation for several years with collapsing roofs and nesting pigeons. Lack of essential equipment as evidenced by the collapse of any endoscopy service at a major regional hospital. This despite four full motivations which were “lost in translation since 2006”. It includes the matter of deep frozen medical and nursing posts. They result in the curtailment of service delivery, the prevention of staff retention and development, and crucially for budding surgeons reduction in operating time. Then of course there is a matter in the driver’s seat that of a market related wage for doctors in the public service which has taken the focus away from the other just as critical issues. I was concerned whether my Interns and Registrars were going to be there and how the surgical department can still run a semblance of an emergency service. I was not relishing being hounded by Human Resources to furnish a positive and negative roll call for my vigilante superintendent. I arrived at my hospital still standing despite several political health policy decisions indicating its demise as a regional hospital and it sale or demolishment. I emerged from underground parking headed for the lifts the only ones in a state hospital where on the premise of efficiency you can only select your floor outside the lift, prior to embarkation. There in the short walkway to the lobby just next to the “Today Tomorrow, Together ATM” was a commotion. There was a lady lying on the tiled walkway with her legs asplay. Several matrons were faffing about her. One was comforting her at the head end and one was between the legs on her knees. The theatre matron had just arrived with a trolley. One with wheels which go round. I was now a yard or two away from the melee and the baby had emerged and was grasped by the matron on her knees. She was so astounded by nature’s success that she immediately handed the baby to the theatre matron who walked away with it to her trolley. There was however, a slight problem. Nobody had either the means or the fore sight to clamp the cord. It went twang. It was difficult to add to the mess on the tiles which was impressive but this did splatter it around a bit more. I thought the baby might exsanguinate. I quickly put my replacement computer from my recent high-jacking down on Matrons trolley, and finger clamped the cord. One of the other matrons with the modicum of obstetric experience took over this task. I then looked at the bloody mess on the tiles which was even more impressive than I noticed at first glance. The matrons were trying to provide a human shield to protect the lady’s dignity from the rubberneckers in the passage. This was only part of their plan as it was now evident from forlorn gaze that they expected me to do something. They even provided me with some gloves for a purpose. I might say that usually little phases me but now I was expected to deliver the placenta. A task I had last done in 1974 as a medical student when as I recall I had an umbilical cord to help me retrieve it. There was no cord in sight, so I then went groping for the cord in the vagina. I then remembered that she still looked pregnant so I pressed on the uterine fundus and pulled gently on the cord and the membranes. The placenta slithered onto the floor. It turned out to be intact. There were no vuvuzelas to herald the great event only the broad grin of a striking orthopaedic registrar who had joined the throng to witness my plight. By this time the essential heavy duty sanitary towel and another trolley with wheels which go round had arrived. The lady with the aid of a caring matron and some strategically draped towels hopped on board her transport to the post natal ward. I am pleased to report that the mum her third child, a baby girl, and my replacement computer are fine. I proudly reported my success to the head of obstetrics. Her district level department delivers each month some 600 babies of which 160 come into this world by caesarian section. This experience certainly brightened my day and helped me to cope with the days ahead. Based on this I was left wondering whether I should change my bank from “Inspired, Motivated, Involved” to “Today, Tomorrow, Together”. I hope, the strike galvanizes all involved in health care provision, to give these words credence. Sandie R Thomson. Surgeon 33 Falkland Place Berea Durban 4001 082468486

Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa

IntroductionThis audit examines our total experience with penetrating thoracic trauma. It reviews all the patients who were brought alive to our surgical service and all who were taken directly to the mortuary. The group of patients who underwent emergency operation for penetrating thoracic trauma is examined in detail.MethodologyA prospective trauma registry is maintained by the Pietermaritzburg Metropolitan Complex. This database was retrospectively interrogated for all patients requiring an emergency thoracic operation for penetrating injury from July 2006 till July 2009. A retrospective review of mortuary data for the same period was undertaken to identify patients with penetrating thoracic trauma who had been taken to the forensic mortuary.ResultsOver the 3-year period July 2006 to July 2009, a total of 1186 patients, 77 of whom were female, were admitted to the surgical services in Pietermaritzburg with penetrating thoracic trauma. There were 124 gunshot wounds and 1062 stab wounds. A total of 108 (9%) patients required emergency operation during the period under review. The mechanism of trauma in the operative group was stab wounds (n = 102), gunshot wound (n = 4), stab with compass (n = 1), and impalement by falling on an arrow (n = 1). Over the same period 676 persons with penetrating thoracic trauma were taken to the mortuary. There were 135 (20%) gunshot wounds of the chest in the mortuary cohort. The overall mortality for penetrating thoracic trauma was 541 (33%) of 1603 for stab wounds and 135 (52%) of 259 for gunshot wounds of the chest. Among the 541 subjects with stab wounds from the mortuary cohort, there were 206 (38%) with cardiac injuries. In the emergency operation group there were 11 (10%) deaths. In 76 patients a cardiac injury was identified. The other injuries identified were lung parenchyma bleeding (n = 12) intercostal vessels (n = 10), great vessels of the chest (n = 6), internal thoracic vessel (n = 2), and pericardial injury with no myocardial injury (n = 2). Most patients reached the hospital within 60 minutes of sustaining their injury. A subset of 12 patients had much longer delays of 12 to 24 hours. Surgical access was via median sternotomy in 56 patients and lateral thoracotomy in 52. The overall mortality for penetrating cardiac trauma in our series was 217 (76%) of 282.ConclusionsPenetrating thoracic trauma has a high mortality rate of 30% for subjects with stab wounds and 52% for those with gunshot wounds. Less than a quarter of patients with a penetrating cardiac injury reach the hospital alive. Of those who do and who are operated on, about 90 percent will survive. Other injuries necessitating emergency operation are lung parenchyma, intercostal vessels and internal thoracic vessels, and great vessels of the thorax. Gunshot wounds of the thorax remain more lethal than stab wounds

Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective

Background. Self-expanding metal stents (SEMS) are widely used to palliate patients with oesophageal cancer. Placement is usually done under endoscopic and fluoroscopic guidance. We have developed an exclusively endoscopic technique to deploy these stents. This article documents the technique and periprocedural experience.Patients and methods. All patients who had SEMS placement for oesophageal cancer at Grey’s Hospital, Pietermaritzburg, South Africa, over a 5-year period (2007 - 2011) were reviewed. Stenting was performed without radiological guidance using the technique documented in this article. At endoscopy, the oesophageal lesion was identified, dilated over a guidewire if necessary, and a partially covered stent was passed over the wire and positioned and deployed under direct vision. Data were captured from completed procedure forms and included demographics, tumour length, the presence of fistulas, stent size and immediate complications.Results. A total of 480 SEMS were inserted, involving 453 patients, of whom 43 required repeat stenting. There were 185 female patients (40.8%) and 268 male patients (59.2%). The mean age was 60 years (range 38 - 101). There were 432 black patients (95.4%), 15 white patients (3.3%) and 6 Indian patients (1.3%). The reasons for palliative stenting were distributed as follows: age >70 years n=95 patients, tumour >8 cm n=142, tracheo-oesophageal fistula (TOF) n=29, and unspecified n=170. One patient refused surgery, and one stent was placed for a post-oesophagectomy leak. Repeat stenting was for stent migration (n=15), tumour overgrowth (n=26) and a blocked stent and a stricture (n=1 each). Complications were recorded in six cases (1.3%): iatrogenic TOF (n=2), false tracts (n=3) and perforation (n=1). All six were nevertheless successfully stented. There was no periprocedural mortality.Conclusion. The endoscopic placement technique described is a viable and safe option with a low periprocedural complication rate. It is of particular use in situations of restricted access to fluoroscopic guidance

The efficacy of endoscopic therapy in bleeding peptic ulcer patients

Background. Endotherapy is the primary modality for the control of bleeding from peptic ulceration. Objective. To assess the efficacy of endoscopic intervention for high-risk bleeding peptic ulcer disease and to benchmark our surgical and mortality rates. Methods. Two hundred and twenty-seven patients with peptic ulcers stratified by Rockall and Forrest scores as at high risk for re-bleeding underwent therapeutic intervention (adrenalin injection) between January 2004 and December 2009. The median age of the patients was 57 years (range 19 - 87 years); 60% were males. Results. Primary endoscopic haemostasis failed in 51/227 patients (22.5%); 18 patients (7.9%) required surgery for bleeding not controlled at initial or second endoscopy; and 29 patients (12.8%) died, 12 by day 3 and 17 by day 30. Fifteen patients, all with significant medical co-morbidity, died after successful primary endotherapy, and 4 died after surgery. Surgical patients required more blood (odds ratio (OR) 1.45, p=0.0001) than those not undergoing surgery, but had similar mortality. Rebleeding was the only predictor of death in patients who died by day 3 (OR 18.77). A high Rockall score was the only predictor of death by day 30 (OR 1.98). Conclusion. The overall surgical and mortality rates were 7.9% and 12.8%, respectively. Over half the deaths resulted from medical co-morbidity, despite successful primary endotherapy. This finding is supported by the use of the Rockall score as a predictor of mortality at day 30. Improving the technical success of primary endoscopic haemostasis, currently 77.5%, has the potential to reduce rebleeding after primary endotherapy, a predictor of death at day 3 in this study

Dietary patterns and colorectal cancer risk in Zimbabwe: A population based case-control study

BACKGROUND: The rising incidence of colorectal cancer in sub-Saharan Africa may be partly caused by changing dietary patterns. We sought to establish the association between dietary patterns and colorectal cancer in Zimbabwe. METHODS: One hundred colorectal cancer cases and 200 community-based controls were recruited. Data were collected using a food frequency questionnaire, and dietary patterns derived by principal component analysis. Generalised linear and logistic regression models were used to assess the associations between dietary patterns, participant characteristics and colorectal cancer. RESULTS: Three main dietary patterns were identified: traditional African, urbanised and processed food. The traditional African diet appeared protective against colorectal cancer (Odds Ratio (OR) 0.35; 95% Confidence Interval (CI), 0.21 – 0.58), which had no association with the urban (OR 0.68; 95% CI, 0.43–1.08), or processed food (OR 0.91; 0.58–1.41) patterns. The traditional African diet was associated with rural domicile, (OR 1.26; 95% CI, 1.00–1.59), and a low income (OR1.48; 95% CI, 1.06–2.08). The urbanised diet was associated with urban domicile (OR 1.70; 95% CI, 1.38–2.10), secondary (OR 1.30; 95% CI, 1.07–1.59) or tertiary education (OR 1.48; 95% CI, 1.11–1.97), and monthly incomes of $201–500 (OR 1.30; 95$1000/month (OR 1.48; 95% CI, 1.02–2.15). CONCLUSION: A shift away from protective, traditional African dietary patterns may partly explain the rising incidence of colorectal cancer in sub-Saharan Africa.IS