That Shaft Shift

THAT SHAFT SHIFT!!!

Somewhere in Mbarara Regional Referral Hospital, Southwestern Uganda

7:30am: My spirits are high, lots of ATP stashed somewhere in my cells, my mood: perfect!! I cannot recall the date. I do know, however, that it was a public holiday and I had been looking forward to this rotation since my 3^rd year of Medical school. This was my first day on the Emergency Ward, which only handled acute life-threatening surgical conditions. The Surgery Resident I was working with that day, a brilliant friendly guy, confidently forecast the day: slow during the day-time, maybe 1 or 2 minor cuts to stitch but brace yourself for the late evening. Check that we have enough 50% dextrose, sutures, local anesthetic and STS (Surgical Toilet and Suturing) kits for the public holiday associated “toxic-traumas”, as he called them.

I was one of those interns that worked like I literary ate ATP for breakfast, and had a tiny 500 Watt generator at the base of my spine. You see, my elder sister is a surgeon, and her colleagues were now my supervisors. Many of them already called me her “little sister” but I intended to stand on my own feet and prove myself.  An hour later, everything is set. I even have the mobile phone number of the anesthetic officer on call.

9:00 am: Calm day, getting to know the nurses and Residents. Chatting about food, friends, family and other things I cannot write here.

9:30 am: I notice a boy about 12 years old, seated in a wheelchair near the A&E gate 30 meters from the office we are seated in. He is calm and lazily watching the happenings on the A&E verandah. I think he is an orthopedic patient, out to bask in the bright-warm Mbarara morning. His parents or caretakers should be around somewhere. The Outpatient clinics are closed today, so there is no traffic through the usually crowded gate. One of the nurses follows my gaze, and interrupts my thoughts
“He is a psychiatric patient. No known relatives. He comes to the A&E often to play on the wheelchairs. He is harmless so we let him be.”

10:00 am: I join the nurses in rolling cotton balls and gauze for sterilization. The boy is still seated there.  This time I take a close look at him. He is unkempt, a bit malnourished actually. He is seated with an almost blank expression, looking right back at me. I notice that the shirt I thought brown was actually originally white, with a collage of dirt, food-stains and smears of other things I cannot identify. The wheelchair is facing away from me and I cannot see his shorts, but his feet are bare and there is a small wet patch on the ground beneath him… perhaps he has wet himself. Something on his lap caught his attention-maybe a toy. He wasn’t looking at us anymore, but concentrating hard on whatever it was on his lap. I keep folding gauze and chatting with the nurses and the Resident. I think I will like this rotation.

10:30 am: The boy is still there concentrating on whatever he has on his lap. He waves his hands randomly in the space over his thighs and I think he is waving away flies. Bored with folding gauze, I decide to go to him and strike up a conversation. He looks up at my approaching frame, and maintains that blank look. Closer to him now, only 2metres away, I could see that there was something amiss with both his expression and posture. I search his face, nothing. My bored eyes slowly move lower and then I see it!!!! 

His right hand is  tightly wrapped around a 3-4 cm long rod-like structure, about the size of my pinkie finger, with bright red blood slowly oozing all over the pink tissue. In his left hand he holds something that looked like of soft black-brown leather. My brain makes the diagnosis but I cannot believe the sight! The nurses saw my expression before I even shouted out Help!!!” Like a skilled surgeon, this mentally disturbed child had separated the skin off his penile shaft with a rusty razor blade that I found beneath the wheelchair. For the past 30 minutes, he had been slowly bleeding and neither he nor the bored A&E staff seated 30 meters away knew of the sad twisted injury going on that could have ended in tragedy.

I wheel him to the resuscitation bed, insert the largest IV line I could find, drew off blood samples while the nurse prepared a minor surgery kit and tetanus toxoid. An hour later, he is stitched, pain free, admitted and the Psychiatrist has come to review him. The Resident and nurses commended my actions but I am still shaken by the experience.

1:00 pm: Lunch time. I cannot stop talking about this case. My Resident tells me to expect anything in the A&E. Only 5 hours and one case but I actually believe him.

2:00 pm: There is no more gauze to fold, and the nurses are busy giving medications. The Resident decides to teach me about patient assessment in the A&E. Somewhere between Primary and Secondary survey, we are interrupted by loud angry shouts. An angry mob is rushing through small gate where the boy had nearly bled to death only hours earlier. Somewhere in the middle of the mob where the crowd is thickest, I see a man in a white shirt stained with spots and smudges of bright red blood; he must be the patient. The patient is supported on either side by two calm-faced burly men, but all around, people are pointing fingers and hurling insults at the man they are supporting.

By the time we get our patient to the resuscitation room, there is a mob of about 40 angry people outside the A&E. The Resident calls the security guard to handle them. I make a mental note to always know where the security guard sits.

The Resident is still with the security guard and I have to handle the case alone for a while. When the patient is placed on the bed, I immediately notice that instead of a trouser or shorts he has a blood stained kitenge (a sarong-like multipurpose cloth that we African women love to wrap around our waists) wrapped around him. I carefully unwrap the bloody kitenge and then for the second time in less than 6 hours I see it again - A bloody penile shaft, with a neat cut at the base where the skin was cut and then peeled back all the way to the tip. The man is in agony!!! I can see the expression on his face - a mixture of pain and fear!!

And this is his story: This 42-year-old man, had been Caught sleeping with a married woman from the same village. He had never paid attention to the several warnings and threats from the woman’s husband. Tired of this, the angry husband and his friends waylaid our patient on a dark village path and left him 10 minutes later with the “presenting complaint”.

The good thing is I now had experience with this particular shaft ‘complaint’ and knew exactly what to do.

10:00pm: Both our patients are doing well, and surprisingly no more severe injury cases.

The Resident (now surgeon) teased me about my “shaft shift” for the rest of my rotation. I learned several lessons that day. At the end of that five month rotation, I knew I did not want to be only a Surgeon. I wanted every exciting bit about every specialty. I had found my calling: Emergency Medicine.

By Annet Alenyo Ngabirano