A Day in the Life at Bangui General Hospital

 A twenty year old man shows arrives in a severe coma after being thrown from his motorbike.  There is blood coming from both ears. When he examined and given a strong painful stimulus he doesn’t open his eyes, makes some crude groaning sounds and flexes awkwardly on only the right side.  On the universal Glasgow coma scale he scores a very poor 6 out of possible 15, keeping in mind that an inanimate object achieves a score 3/15.  He pupils don’t react to bright light but they remain equal and only moderately dilated suggesting that the swelling on the brain isn’t enough to push the cranial contents toward the funnel at the base of the skull.

In a word, it’s bad.  Anywhere back home he would be immediately have a breathing tube inserted in the trachea and placed on a ventilator and taken to the CT scanner and to an operating room for decompression and to address any bleeding. It doesn’t take a brain surgeon to figure out that he needs access to an immediate operation and an intensive care unit to have any chance of recovery. 

In Bangui we have the capacity to do neither.  Our team has the capacity to do neither.  Our ICU consists of four beds staffed by two nurses, has the capacity to obtain regular vitals signs and provide oxygen from a concentrator up to 5 litres per minutes which isn’t that much.   We have two surgeons, an orthopod and a general surgeon.  If we bring him to the operating room and place him on one of our two ventilators he wouldn’t come off for days, weeks or never.   This would severely limit our ability to provide surgery for the rest of the population.  

Our French orthopedic surgeon from New Caledonia did some basic neurosurgery this week in response to a head injury from a grenade blast.  The patient was not severely injured in the sense that he was conscious but bleeding from his middle cerebral artery on the side of the head.   He was able to stop the bleeding and leave a drain on the layer just outside the brain. It is a very difficult decision but it turned out quite well as he is recovering with some occasional mild confusion.  If he doesn’t get infected he will likely do quite well. 

The bulk of the orthopedic patients we see are fractures from road traffic accidents.  Motorbikes are not your friend in CAR. Since internal fixation (placing rods and hardware in the bones to set them) isn’t possible due to infection risk most are splinted or placed in traction for 60 days.  At first it appears rather crude to see a trans-tibial nail but it is an effective treatment.  Jugs of water tied to the pin provide the counterweight required to maintain the traction.  The act of placing the pin doesn’t require much in the way of anesthetic.  A little freezing medication at the entry and exit site just below the knee, a few taps and it’s over.

There is no shortage of violent trauma in the form of gunshots and stabbings.  I suppose there is not a weapons shortage here. The ER only calls us for the severe ones.  This past week we had the grenade attack that brought two to the OR resulting in chest and abdominal trauma that resulted in a splenectomy and the minor brain surgery mentioned.  The same day there was a shooting by that resulted in 2 dead and three minor injuries that we took to the OR to remove Kalashnikov bullets from an arm and shoulder.  Machete or knife attacks seem to occur on a daily basis and the more significant ones are taken to the OR to explore and close the wounds. Travel by night is often very difficult and some patients arrive the following morning with significant wounds. 

We have been averaging about one bowel case per day often from longstanding hernias that acutely strangulate and cut off blood supply to the bowel.  The large abdominal incisions would certainly get an epidural back for pain relief back home but the conditions in which we work don’t allow such interventions.  I mitigate with an ultrasound guided abdominal nerve block at the end the case.  It is amazing how resilient these patients are in terms of pain resistance. In fact I have to scale back on morphine during the anesthetic because they take too long to wake up after the surgery. 

Fractures, stabbing, shootings and abdominal surgery makes up standard operating room caseload most everywhere in the world.  The frequency and severity of infections that present is rather impressive.  Every day patients arrive with week old infections of the hands, leg or feet that require significant debridement and in hospital treatment.  We are now doing a skin graft per day on old wounds that require coverage to complete the healing process.  In ripe infectious conditions like this it is a carefully weighted decision to provide a skin graft.

News from home included that the dog was acting a little off.  The subsequent veterinarian consult and options for investigations baffled me more than usual.  Since some of his bloodwork was off they offered to provide a steroid stimulation test and heart ultrasound.  I am always amazed at the capability for animal care especially when the customer is willing to pay.  The absurdity that my capacity to provide care for my dog outpaces what I can do for my patients in not lost on me.