Surgical Casualty at Mulago

I woke up early, and decided to go into Mulago for half the day. I was supposed to start a new rotation on the surgical casualty service. When I arrived, Peter, the intern, was busy suturing up a head laceration – the result of a boda boda (the motorcycle-based passenger service in Uganda) accident. Most of the other patients that were waiting were all there because of boda boda accidents, or fist fights. And here I thought that there was no violent crime in Kampala. Who would get into a fist fight early on Saturday morning?

I introduced myself to the intern, and he asked me if I knew how to suture. Of course, I’d love to help you suture up some lacerations. Did they use Sub-cuticular stitches for facial lacs? You know, to optimize the cosmetic outcome? “I would if I had time,” the intern replied, “but I don’t. So no.” Ok then. He directed me to the patient waiting on the other bed. Apparently, my patient was the boda boda driver, and his patient was an unfortunate pedestrian who had been knocked over my patient. And they were both in the same room, lying next to each other, awaiting treatment.

My patient had a very deep and long laceration right underneath and along the length of his left eyebrow. The only syringes we had available to inject lidocaine with had needles so large, I wouldn’t want that thing going into my deltoid, much less close to my eye. But it was the only thing we had, so I used it to inject him with what I thought was an ample amount of lidocaine. However, I was really worried about poking his eye (I was working so close to his eyeball), and so proceeded very carefully and slowly. I tested his pain sensation with the tip of the needle, and he seemed to be fine. So I started. But as soon as I started my first stitch, he started pulling away in pain. And I had to follow his head movements with my suture and pickups. He kept fidgeting in pain. After a few painful stitches, he asked me why I couldn’t give him any anesthesia. “But I already gave you a lot,” I replied. I spoke to one of the sisters, who told me that he was probably an alcoholic, and alcoholics are insensitive towards lidocaine. It was true. His breath did reek of alcohol. So I gave him another hefty dose of lidocaine, and he behaved a lot better. I finished up and put a bandage over his wound. Then I asked him if he could move his eye from side and side, and up and down. “No,” he replied, and I felt a cold cold chill run down my spine. I had sutured his eyeball!! And I had been so careful!! But upon further inquiry, it turned out that he couldn’t move his eye because of all the swelling around his eye. If he tried very hard, he could move his eye any which way he pleased. Phew! What a massive relief!!

And I left my shift a little bit early to go buy a helmet. No facial lacs for me please, thank you very much.