Stab wounds and surgery ***WARNING: graphic pictures***

Before I explain my rather dramatic title (for which I apologise but I am feeling rather dramatic at 5.30am after only a few hours sleep a for the second time this week) I would like to reassure you that the words Tombo and stabbing do not usually go together.

In the albeit relatively short time I have lived and worked at the academy I have not seen more than a minor scuffle swiftly sorted out by the involved parties and several excited onlookers. Tombo is pretty quiet during the day and becomes a lot busier at nighttime but even so I have always felt comfortable walking around the village at nighttime, although clearly not on my own, I am far too much of a wimp for that!. So please be reassured before you continue that the following blog post concerns events definitely out of the ordinary and hopefully a one off event.

Other than our friendly overbearing pastor blasting out the word of God at 4.30am several nights a week (more on him later) the only other time the peace of the night is disturbed is when Tombo decides to have a party, and by party I mean all night rave, African style. Huge speakers are plugged into noisy generators, blasting Afro beat from sun down to sun up, hundreds of people milling around, street sellers selling cheap booze and food and I'm sure the odd recreational substance also - not so dissimilar from your illegal parties around the world I guess, except this is not only completely legal but an actual organised event. Canvas fences are set up around the area and the whole village and surrounding villages seem to turn up, with tickets usually being sold on the door (quite why you’d pay to enter when you can stand a mile away and hear the music I’m not sure)

Now I have not attended one of these events so the information I have on them is limited to third party gossip but I have been assured that security is in place and the local police attend so that for the most part these events are good fun and fairly safe. The only issue are the thieves. Large crowds will inevitably draw the local thieves in, ranging from pickpockets and muggers at the event to robbers combing the empty village houses for forgotten money and the odd valuable item.

Now as frustrating as all that is for the locals that simply want to have a good night, it shouldn't affect us at the academy; we have security on site, we are relatively far away from the main events, all of our valuables are locked away and surely none of the staff would  attend one of these events right? Wrong. 

Let me introduce you to Daniel. Dan in a plucky 23 year old graduate who is currently the CBF science teacher and maths teacher. Dan has well and truly integrated himself with the local community in Tombo and generally spends most of his free time at the orphanage next door or sightseeing with one of the orphanage staff, Ishmael. The children of Tombo flock to Dan crying out his name like the legendary tale of the pied piper and you can regularly find him having a chin wag with the local security guards.

It's thanks to Dans close friendship with the orphanage staff  that I found myself being awoken at 4.30am on a Sunday morning by the academy physio. Brendan is usually full of wise cracks and manages to find the fun in pretty much any situation, so to find him looking very serious outside my door was somewhat alarming to say the least. I can't completely recall the exact conversation due to my sleep deprivation at the time (2 hours having gone to sleep at 2.30 am thanks to the loud music) but I believe it went something like this:

Brendan - "so Dan went into Tombo to the party and he got punched... There's blood, a lot of blood"

Me - "err.. Right.. ok.." (mentally - f*&k, s”@t and all manner of expletives)' 

Later I found out that Brendan had been woken by Dan calling into his bedroom window saying that he didn't want to alarm him but.. so I guess I got off pretty lightly.

Off I went to the medical room in the pitch black where I find Dan lying on the physio table with an arm covered in blood and Brendan holding an insanely large number of pads firmly against his arm attempting to staunch the bleeding. At this point adrenaline has well and truly kicked in so I feel awake and ready to go and don't even think about the bizarreness of any of this until much much later. 

Upon questioning Dan relates his account confirming that he was at the party with Ishmael but decided to go outside the canvassed off event 'arena' to avail himself of the public toilet facilities (the ditch) on his own. Whilst availing himself, for want of a better description, he noticed several guys approaching him. They kindly waited for him to tuck himself away and zip himself up before attempting to rob him. One of the men kicked him whilst another placed his hands in Dans pockets looking for his phone or money - he'd have had a job finding anything, Dan had left his phone at the Academy and having been out since about 10pm only had 5,000 leones remaining (about 80p)

Dan being the sharp cookie that he is managed to shrug them off and run back to the main area. Unfortunately our friendly locals decided to follow him into the event. As they caught up with him Dan called for help, a call which unfortunately went unanswered. As the would-be-robbers caught up with him Dan saw one of them throwing a punch that caught him on the arm. Dan continued running away and it was only when he tripped over a short time later that he noticed his arm was covered in blood. Dan says he felt no pain at the time - adrenaline is a wonderful thing. At this stage Dan still thinks he has merely been punched but there is a lot of blood so he finds Ishmael and they head back up to the Academy for help.

So a short while later its 4.30am and you can find Brendan and I in the medical room looking at a pretty impressive wound that is still bleeding quite profusely. Brendan does an excellent job applying pressure and eventually the bleeding subsides to a manageable level, we even managed to have a bit of a joke while we wait. We then have a proper look at Dans arm. The wound itself is beautifully neat - straight sides and fairly clean so at this stage it wouldn't have surprised me if it had been caused by a large ring impact ring and splitting the skin. It's only later that Dan notices the rip in his t- shirt sleeve and we discovered the wound is actually a stab wound from a small knife - probably something I should have looked for straight away but I don't think any of us were firing on all cylinders and we did a pretty good job under the circumstances! 

The wound itself is fairly small - about 1.5cm but fairly deep so it definitely needed stitching. We patched Dan up for a few hours until they could head off into Freetown to get it stitched. I should probably point out that you can get stitches at either of the two local clinics near the Academy, however one I would not trust in the slightest and the second, whilst an excellent minor clinic that I regularly take the boys too, does not have any anaesthetic and I didn't think Dan would appreciate that too much! Brendan took him in whilst I headed off to the beach - I meant to sleep but the best laid plans and all that! Plus I was due to be heading into Freetown the next day to do the weekly shop and couldn't face it two days in a row.

Dans pretty impressive stab wound.

Several hours later they return, minus stitches. The doctors at the hospital had confirmed that knife wounds need to be left open and cleaned out regularly to prevent infection and that Dan must go back the next day to be seen again… I am quite literally speechless at this astounding stupidity and arrange to go in with Dan the next day to rant at the doctors and make sure this gets sorted. I was pretty shocked to be honest, particularly as this is one of the most expensive hospitals in Sierra Leone and coincidentally is where I was treated for Malaria back in November. When I was in I had a few issues surrounding basic protocols such as not using needles you have dropped on the bed etc but the general knowledge of the nurses and doctors I found to be pretty good.

The longer a wound like Dans is left open the greater the risk of infection, particularly in a country like Sierra Leone. Any packing done by the hospital in an attempt to prevent infection merely serves to provide an attractive moist little hot house for bacteria to breed and causes the skin to whiten and shrivel - something similar to when you have been in the bath for a long time. Not only this but your body has a remarkable ability to protect itself and, having sustained a wound, will shut down the blood supply to the edges of the wound to prevent further bleeding and to try and protect itself from infection. Pretty amazing really but not too helpful when you want to stitch it back together - dead skin doesn't fuse and the wound would break down again, internally and externally.

So the following day finds us back at hospital. Right off the bat I have a disagreement with the nurse on the desk duty who claims there is no surgeon so regardless of what I want there will be no stitching today. After much argument the nurse takes us back to a back room and removes yesterday's dressing. I was not impressed by what I saw. The previously beautifully neat wound is now puffy and oozing and not looking healthy in the slightest. 

Day Two - still no stitches and looking worse for wear.

The nurse tries to fob us off with the same packing and cleaning story saying to come back on Wednesday until I lose my temper. A doctor is called, an Indian lady, who initially agrees with the nurse until I argue my point and then says we need to come back the next day to see a surgeon as it's only them that can suture. Clearly this was unacceptable to me so I very politely reiterated my point.. 

That's a lie, I’m sure I wasn't very polite but I obviously managed to get my point across as twenty minutes later we were in a taxi heading across town to see the surgeon at his private clinic.

Once Dr Bayorh and I explained what had happened I took great delight in listening to him phone the hospital and speak to the on duty doctor. It would appear he was equally as unimpressed as I was and even less polite than me. Without undressing the wound as he was so concerned about infection now he agreed to see us urgently back at the hospital an hour later to stitch the wound. 

Our second visit to the hospital looked like it was going to go a lot smoother, the previously pushy nurse was full of smiles and offers of assistance as he took us through to wait for Dr Bayorh. Dan even commented how grateful he was that it was finally going to get sorted - big mistake. 

Dr Bayorh took one look at the wound in its current state and confirmed he would in fact be unable to stitch it that evening as the wound was beginning to show signs of slight infection and the skin condition had degraded to such a point that he would need to surgically widen the wound to ensure it would heal correctly and without a major infection. Dr Bayorh seemed to know his stuff and was happy to show me how deep the wound had gone and why he was concerned so I begrudgingly accepted that I would be back into Freetown the next day.

As I write this I am hurtling along in the dark frantically trying to recall if a sharper bend than 25 degrees lies anywhere at the distance and if so how much waning will I have before we lurch off the road to what is guaranteed to be an excruciating death awaiting an ambulance that does not exist whilst the locals gawk at the bleeding white girl before picking over my broken body for valuables - it's alarming how active my imagination is at 5.39am after 3 hours sleep. 

At least we are driving at night so have the lights of the other vehicles to guide us.. Excuse me, I appear to have forgotten where I am for a second! This is the country where any thing goes when it comes to the roads and the vehicles that use them. Last night on our weary return to the academy we were forced to overtake a large ancient lorry that was churning out enough smoke to blank out the whole of South East England. Although that may be a good thing when placed in the right location… 

Mid overtake the surrounding scenery (admittedly not too clear anyways at night) and lights from the other vehicles and roadside disappeared. For what felt like a lifetime we travelled through the thick black smoke completely blind. The experience was enough to make our staunch driver exclaim in surprise (which for a man that likes to take a certain uphill steep corner in Freetown at rally speed to see how fast he can push the van is pretty unusual)

I digress, back to vehicle lights. You are lucky if your vehicle has them at all to be honest. The rickety old taxis that rattle along at neck breaking speed regularly drive using their hazards lights - a truly alarming experience - and it's not uncommon to see a single headlamp in use making the car look like a bike. And yes I am using the term car extremely loosely.

I have come upon a useful survival strategy for journeys such as these though. The trick is to not look ahead and think of the journey as a roller coaster you are not quite sure of. The twists, the turns, the screech of brakes and heart stopping speed - at the time you curse under your breath as swear you’re not ever going to ride this coaster again but the fear is soon forgotten upon leaving your carriage and it's not too soon before you complete the same mistake again and take just one more chance on the coaster.

The streets of Freetown at 6am are just as hectic but in a completely different way. I can finally breathe again as the hustle and bustle of people preparing for the busy day ahead forces the taxi to slow down but now I have to deal with the sudden momentary panic as people dash across the front of the car with goods, wrongly assuming the car will slow down to allow them to cross. Admittedly I have never seen a person hit by a car in Freetown but I have seen several hit by the motor bikes that weave in and out of the traffic. I’m not entirely sure of the protocol if we should hit someone - do I stay in the car for fear the white people will be blamed and I shall have to batter away attempts to procure money as compensation and allow the driver to handle it? If so, how easy will it be to ignore my desire to get out and assist the injured party if I can? I should probably find out what is the recommended course of action as it may well happen at some point, so far the CBF driver has only hit stray dogs and the taxi drivers although manic have always been just as good.

We make it to the hospital and they start to prepare Dan for minor surgery - under my watchful eye of course. Initially they try to request a canular is put in and when I question the necessity of this for a local anaesthetic they exclaim that it is essential in case the surgery has complications and they need to put Dan under a general. I immediately deny them this stating that under no way shape or form is Dan being placed under a general anaesthetic as I am not comfortable with this, particularly the intubation they then move on to suggesting. To my surprise I am told not to worry, if it is necessary they will come and collect me and I can do the intubation… I think I may have turned slightly green at this point but not wanting to alarm Dan I merely confirm that an IV line is not necessary and if there are any complications I will discuss them with the surgeon at the time and to my relief they agree.

Dan gets a bit of a shock himself when he puts his surgical gown on and the nurse admonishes him for putting it on with the name label on the inside. I joke the label is required in case they forget who he is and think he is in for an amputation instead but I don’t think he found that amusing, perhaps I should rethink the timing of my jokes sometimes.

Soon enough the surgeon arrives and they wheel Dan off the surgery in a wheelchair with me shouting behind him not to worry and if they go to do anything different than I have already explained for him to ask for me first!

I settle down on a bench outside for a long wait with fingers crossed that there will be no more surprises or disasters.

Later on:

Well today has certainly been a different day for me than usual. I have just been inside an operating theatre whilst minor surgery has been carried out. 

Not long after Dan was taken through a theatre nurse called Sandeep came to collect me and asked me to scrub in, all the while calling me Sister which is what they call the senior nurses here - slightly concerning! 

I was taken through to the nurses changing room and given a set of scrubs, clogs, mask and hat to change into and then taken to ‘scrub in’ 

Walking into the operating theatre I see Dan looking pretty happy, but looking decidedly away from the surgeon and his arm. I can understand why - The small wound on his arm is now at least three times the size! The surgeon carefully explains why the wound is larger and shows what good condition the tissue looks in now. I have to say he has done a good job, all the gunky tissue has been removed and all the edges were bleeding nicely - a good sign as it shows the blood flow to the edges of the wound which is essential for healing once it has been stitched up. I am very confident in Dr Bayorhs ability, particularly compared to the alternatives we have already seen several times in the last few days so tell him it look good and I’m happy for him to stitch Dan up.

I stood and watched the Surgeon put in five internal stitches directly into the muscle and then close the wound with about 8 external stitches. A surgical drain is put in and I explained the purpose of this to Dan as they don't tend to explain any procedures here to the actual patient! 

Pretty gruesome looking (several days after surgery)

When it all looked good and they were cleaning Dan up ready for the wound to be dressed I headed back out to get changed and one of the Theatre nurses asked to take my picture for me in surgical gear.

 

Scrubbed and ready to go

Dan managed to walk out the operating theatre and back to the day patient ward where I am told he needs to rest for twenty minutes in case he starts to feel nauseous and then he can go home. One of the nurses comes over with a prescription without any explanation and I tell Dan he has been prescribed an antibiotic and some painkillers, the nurse overhears this and exclaims that I know more than they do - I sincerely hope not!!

The final battle of the day begins where I have to argue with the hospital administration that no, I am not paying for the use of the theatre etc as if his doctor had treated Dan correctly on the first day he would not have needed minor surgery and eventually I manage to cut the bill in half and can take Dan back to the Academy. I’m very impressed at how Dan has handled all of this, he has been an awful lot calmer than I’m sure most people would be and at the moment is determined to remain at the Academy unless I see signs of infection in which case I have pre-warned him that I will be pumping him full of antibiotics and putting him on a plane myself, regardless of whether he wants to go or not.

This has definitely been an experience for me and has also made me consider my options for future careers in Africa maybe. Who knows maybe I might attend a university here to get a nursing degree or even become a doctor, particularly as it would appear I already have half the knowledge required(!!). I think I would want to go somewhere like Kenya to do this though ,where it is so much more developed, as I am not sure I could handle being ordered to follow protocols that even I know to be bad practice. Its certainly a thought for the future though.

Several days later:

We headed back to the hospital a few days later for a check up and to have the drain removed. The wound looked good with no sign of infection at all., so I am quite happy with the result. 

Coming along nicely

Following discussions with his family, Dan decided he would head back to the UK for a full check up and is currently there where he has received the ok from a UK nurse  and had his stitches removed. Get well soon Dan and looking forward to having you back in a few weeks and remember, at least you have an awesome story to tell about your time teaching in Sierra Leone.

Nearly healed :)