Mosi oa Tunya, the smoke that thunders, is the local name for Victoria Falls. It is also the most popular brand of beer in Zambia. If you are of a squeamish disposition, stop reading right now.
“This one’s for you, doc,” said Nurse/Midwife Regina. “I don’t know what it is or what to do with him.” I looked at the cheap school exercise book which we use for patient records. There was a single clinical entry, “Chest pain, swelling.” I ushered the gangly 16 year old boy into my consulting room and asked him what was wrong. “Chest pain and swelling,” he replied, pointing to his lower left ribcage as far as his right hand could indicate.
When he took off his shirt, I could see a fat, sausage-shaped swelling, following the line of his lower ribs. The front part of the swelling felt fluctuant, as though there was some fluid inside it. The sides of the swelling were firm, almost hard, and difficult to define. It looked as big as a 500ml bottle of water.
“How long have you had this?” I asked.
“Four months, since I fell off my bicycle,” he replied.
“Four months? Why did you wait so long to come to the health centre?”
” I did come, but they said it was fine and it would get better by itself. Now it is paining me.”
My first thought was that it was an abscess, but there were other diagnoses to consider before I attacked it. I stuck the fattest needle I could find into the part of the swelling which felt softest, and tried to aspirate pus. Nada. Nothing. Not a sausage. This might be because the pus was too thick, or it was loculated and I had missed the collection. Or I might be completely wrong and it could be necrotic fatty tissue, damaged in the accident. And really low down on the list of possibilities was a primordial neurectodermal tumour (Ewing’s) attached to rib. I have seen two of these in young people in my career, and it is a condition one doesn’t forget.
The queue was getting restless, so I asked him to return in the afternoon for minor surgery under local anaesthetic. I thought this would give me some time to prepare, and I wouldn’t feel pressurised.
I asked Daillies or Regina if they wanted to see what I was doing, but they declined. I asked for some sterile instruments, and these were removed from a metal tray which had been covered by a blue drape. Goodness knows when they had been sterilised. I got some local anaesthetic and a blade, but when I asked for gauze swabs, I was informed that these were “O/S” or out of stock. I would have to make my own, using a gauze bandage. Daillies likes cotton wool (I hate it; it sticks to everything). She put a large handful into the kidney dish.
The young man got up on the examination couch and took off his shirt, scrunching it up for a pillow. He lay down on his right side and I painted the swelling with iodine. I injected 10ml of 2% lignocaine local anaesthetic and picked up the scalpel blade. One thing I have learned about minor surgery is that skin is often thicker than it looks, so I cut a deep incision into the same area where I had tried to aspirate.
This time there was a gush of pus which quickly overwhelmed my scrawny, self-made gauze swabs. I reached for the kidney dish to catch the effluvia, but it was too late. A fountain of pus was spurting from the wound. I shouted for some help, but no one came. This was odd, because there are no ceilings and you can usually hear what people are saying in nearby rooms.
The lad looked down at his side and said, “Mosi oa Tunya!” Well, I wouldn’t say it was that impressive, but he was insistent. “Have you ever been to Livingstone and seen the Falls?” I asked. “No, but I have seen the picture on the beer bottle label,” he replied.
By now, the kidney dish was overflowing. The wodge of cotton wool was worse than useless, sticking to his skin in thick whisps. His jeans were getting soaked and I just hoped he had not put his mobile phone in his right jean pocket.
Once the flow had eased, I slipped an artery forceps into the wound and broke down any pockets of pus, then I cut up a piece of sterile dressing to make a wick. This would prevent the wound healing over prematurely, trapping pus inside.
Daillies finally came to my rescue and was transfixed by the scene. Pus everywhere. The patient was beaming in delight at seeing all the corruption which had burst out of him. And I was wondering about the wisdom of wearing a white shirt to work. We applied a dressing and asked him to return tomorrow morning. He was smiling, despite wearing jeans which had been soaked in pus.
The following day, the wound looked clean. The swelling had disappeared so I could examine him better and try to work out what had happened. This was probably a haematoma, a blood clot, caused by falling from his bicycle. The clot had subsequently become infected, causing the abscess. The hard areas around the swelling were healing broken ribs, which were lumpy with excess disorganised bone. It should eventually remodel into a smooth rib again. Unless the irregular bone represents osteomyelitis, and this is a “sequestrum” of dead bone. It would have been useful to have some imaging but the nearest X-ray facility is 55km away. If it heals nicely, my working diagnosis is correct, but if it forms a discharging sinus, I will give him a long course of antibiotics.