LP Mulago-style

Today, I attempted my first LP here, my second one ever. The first one had not gone smoothly, no champagne tap as such. I had been on my third year neurology clerkship, and had attempted the LP on a young thin woman with suspected MS. I fidgeted with the needle for about 2 minutes, and then my resident came over, readjusted the needle, and within seconds, clear CSF was pouring out of the needle. “You were close,” he consoled me. “Not close enough,” I muttered.

I really hoped that this one would go better. And then I realized that instead of an LP kit, the only tools required for an LP at Mulago is an 18-gauge cannula, a pair of sterile gloves, and some cotton balls soaked in Iodine. I found my landmarks (ASIS) and then made an imprint in the intervertebral space with my thumb nail. And then wiped the area with the iodine-soaked cotton balls. I donned my sterile gloves, removed the guide needle from the cannula, and proceeded to stick the guide needle into the patient’s back. No local anesthesia was available for this procedure – we only use Lidocaine for biopsies. It was a lot tougher to advance the needle in than I had expected. I met with a lot of resistance. “Just keep advancing,” Dr. Wilson instructed. I hit a point where I couldn’t advance the needle any further. No CSF was flowing. I readjusted the needle, trying to aim for the umbilicus as I had been taught. No luck. I took the needle out, repositioned it, and tried again. This time I hit bone almost immediately. The patient howled with pain. “Musawo!!!” she screamed. I pulled the needle out, and asked Dr. Wilson to take over. I did not want to subject the poor woman to any more of my untrained fumbling. Dr. Wilson aimed, pushed the needle straight through the woman’s screams and CSF gushed out into the awaiting tube. I could only wish for those mad skills. “I hate being bad at things, especially when being bad means my patients suffering.” “Don’t worry,” Dr. Wilson encouraged. “You’ll get it next time.” I spent the rest of rounds trying to avoid the death glares the unfortunate patient shot my way.