high-impact education
After working as a surgical registrar in South Africa, Sylvie Dubois-Marshall wonders: Are British surgical trainees missing out?
"A young man presented with a swollen neck – he had been stabbed a few days previously and had attended casualty where the wound was sutured. A soft tissue X-ray showed that the blade was still in his neck!"
I was working as an SHO in the UK and was growing increasingly frustrated by my lack of progress. Opportunities in theatre were limited – the only operation I had performed completely independently was the incision and drainage of abscesses. I had just completed my MRCS examinations and had a good theoretical knowledge, despite limited surgical skills. Therefore, I applied for a surgical registrar post at Ngwelezane Hospital, a tertiary referral hospital in rural KwaZulu-Natal, South Africa.
One hot summer night, we sweated under green plastic aprons, double gloves and visors (around 40% of our patients had HIV) whilst the air conditioning heated the air! Nonetheless, I was working in South Africa: terrified, excited and learning exponentially. The patient was an overweight, elderly man who had been shot in the abdomen. I was struggling to mobilise the left colon – the bullet had gone through the bowel multiple times, leaving only a few undamaged segments.
The patient was cold and his general physiological condition deteriorating, so I called my consultant. When he arrived, I watched with fascination as he used a linear stapler and then blue tape from abdominal swabs (we rapidly ran out of staples) to isolate healthy sections of bowel, removing damaged areas in between. Once the contamination was contained he washed the abdomen and closed it with an opsite sandwich: a layer of abdominal swabs between two layers of opsite. After less than half an hour, the patient went to the ICU.
The consultant explained that the aim of this operation was to stabilise the patient (in this case by controlling contamination from bowel content) and was a part of the resuscitation process. It was not the time to be re-anastomosing multiple sections of bowel in a prolonged procedure that, in a cold acidotic patient, could prove fatal. The patient was returned to theatre the next day and the anatomy dealt with more definitively.
As well as being exposed to major trauma, I also witnessed a wide range of diseases. One evening, a young man presented with a swollen neck – he had been stabbed a few days previously by his brother and had attended casualty where the wound was sutured. A soft-tissue X-ray showed that the blade, about 15cm-long, was still in his neck! Horner’s syndrome and partial clawing of the hand contralateral to the stab had also been missed. The blade was successfully removed in theatre.
Trauma training is limited in the UK due to reduced incidence and increasing sub-specialisation. However, my invaluable experience in South Africa shows that trainees can rapidly obtain basic but important management skills. In particular, I found the concept of utilising the operation as a step in the resuscitation of certain trauma patients novel and effective. As one consultant explained, ‘It’s about steering the sinking ship back to port – detailed repairs can be done later.’ My greater responsibilities and involvement in the care of patients increased my practical skills and, above all, my confidence in managing all aspects of surgery – from admission, through theatre, to discharge.