Published 10 December 2008, doi:10.1136/bmj.a2958
Cite this as: BMJ 2008;337:a2958

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A chance of life

¹ London

The surgeon David Nott, a Christian who does regular voluntary work abroad, made headlines last week when he recounted how he used instructions sent by text message to do a forequarter amputation on a boy in the Democratic Republic of Congo. Here he tells the story in his own words

Every year I volunteer to work for a month as a surgeon for Médecins Sans Frontières. I have worked for the charity since 1994, in Bosnia, Afghanistan, Liberia, Sierra Leone, Ivory Coast, Chad, and Darfur, Sudan, and this year I was posted to work in the town of Rutshuru in the war torn eastern territories of the Democratic Republic of Congo.

On my first round I noticed a 16 year old boy lying almost motionless in one of the surgical wards. The surgeon that I had replaced had had to do an emergency left upper limb amputation for a severe injury several weeks previously. The cause of the injury wasn’t clear. I was told that it may have been a hippopotamus bite, but when he recently became better it was revealed that he had been caught in crossfire.

He was very septic and unwell. Taking down the dressings showed a very infected stump. The muscles were becoming gangrenous, what was left of the humerus was infected, and the skin had that tinge of ischaemia.

I believed that this boy, if left, would have a certain miserable death. The only way to treat him was to perform an emergency forequarter amputation. Though a consultant vascular surgeon for the best part of 16 years, I had never seen one nor been involved in one. It is performed only very rarely in the United Kingdom, in specialist centres that deal with upper limb malignancies.

I am fortunate that I know and work with Professor Meirion Thomas at the Royal Marsden Hospital, London. We work together regularly, performing cancer operations that require vascular reconstruction. He probably has the greatest experience with forequarter amputation in the UK.

Communications in eastern Congo are mainly by mobile phone. The internet infrastructure is very basic. I decided to text my colleague to tell him the problem and also to ask him to relay instructions on performing a forequarter amputation. This he did almost immediately. I thought about the operation and the instructions that he had relayed to me and asked him to text some further instructions I wanted so that I could fully assimilate the knowledge.

I spent the next 24 hours planning and drawing the operation on pieces of paper. My concern was to place the incisions in the right place so that I would get the skin flaps to oppose once I removed the shoulder with Meirion’s instructions. I discussed the patient with my Congolese surgical colleague and the anaesthetist and planned to do the operation the next day.

The hospital in Rutshuru was very basic but very well stocked. We had two operating theatres with sufficient lighting, ventilators for the anaesthesia, and surgical sets that contained all the instruments that would be needed for a variety of operations, such as caesarean section, laparotomy, and fracture management. There was no equivalent of an intensive care or high dependency unit. For the operation we could muster only one unit of cross matched blood.

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I had had the opportunity to work with the Congolese anaesthetist, Paul, on several cases before this one and was very impressed with his skill. Although he is not medically qualified, being a nurse trained in anaesthesia, he is able to perform spinal, epidural, and technically difficult anaesthesia involving intubation and ventilation.

The operation, which took about three hours, took place with the patient in the lateral decubitus position. The incision started on the clavicle. I used a Gigli saw to remove the middle third of the clavicle and then dissected, ligated, and divided the subclavian artery and vein individually. I then divided the trunks of the brachial plexus as high as possible in the root of the neck.

The incision extended around the front of the chest, dividing the pectoralis major and minor muscles. It then extended around the back, following the whole of the medial aspect of the scapula, and all the muscles were divided off the scapula. All the blood vessels were ligated.

I lifted the scapula forward and divided the serratus anterior and trapezius muscles, including all the muscles of the shoulder girdle. The skin incisions were then joined up and the whole of the shoulder removed. I sutured his skin with interrupted 2-0 Prolene.

Once finished, I was delighted when the boy woke up and was transferred to the surgical ward. I was very impressed with the Congolese nursing staff, because although faced with not the cleanest of environments, they used strict aseptic technique to change his dressings.

This operation, it has to be remembered, took place in October in the midst of fighting. While he was there the surgical ward had a significant turnover of patients. One morning we received 75 patients with gunshot wounds that had to be treated. These were soldiers and fighters from the rebel forces and the poor civilians caught in the crossfire, including pregnant woman and children. During this time the team, including me, operated non-stop for 22 hours on one occasion. Not a single patient died, testament to the dedication of the teams and sheer professionalism of all those working on that day.

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I texted Meirion to tell him that the operation had gone to plan, and he texted back to say how happy he was. [Full texts are published below].The postoperative course could have been very different if the skin flaps or a haematoma under the wound had become infected, but, with careful changes of dressings, antibiotic treatment, and careful fluid management, no postoperative complications ensued, and the boy very slowly started to get better.

Apart from the operation itself I faced a dilemma: was I was doing the right thing to perform surgery on a young boy who had such a high perioperative risk? I calculated that he must have had a perioperative risk of death of around 80%. This was on the basis that he was so sick, we had only one unit of blood, and at any moment we might have had to receive a massive number of war wounded, and as a consequence I would have been on my own without an assistant.

I also wondered what life he would be left with if the operation was successful. To be aged 16 in Congo with no prospects, what would the quality of his life be like? However, I had to put those concerns to one side; that was for another day. The ethos of Médecins Sans Frontières is to save lives throughout the world where otherwise people would die.

I understand that the boy has been tracked down by a French journalist. He is well and has been discharged from hospital and is now living in a village about 100 km to the east of Rutshuru.

This boy, through me and Meirion 7000 km away in London, had another chance at life. I would never have been able to carry out this procedure without the help of the text messages. I can only say that God works in mysterious ways.

Médecins Sans Frontières has missions throughout the world, mostly in countries where the healthcare system has broken down. For thousands of people its medical facilities are the only ones available. It cares for displaced people, the old and young, and all those needing treatment in times of war. It is always looking for volunteers, whether medical, nursing, or paramedical. If you want to help personally please visit www.msf.org.uk.

First Message Start on clavicle. Remove middle third Control and divide subsc art and vein. Divide large nerve trunks around these as prox as poss. Then come onto chest wall immed anterior and divide Pec maj origin from remaining clav. Divide pec minor insertion and (very imp) divide origin and get deep to serratus anterior. Your hand sweeps behind scapula. Divide all muscles attached to scapula. Stop muscle bleeding with cont suture. Easy! Good luck. Meirion Second message You must start by removing the middle third of the clavicle as that gives you the best access to the subclavian vessels which pass diagonally behind the middle third. Take the roots of the brachial plexus as far medially. Then get beneath the origin of serratus anterior (deep to pec minor) and then sweep your hand beneath the clavicle. How is the hippo? Meirion

Cite this as: BMJ 2008;337:a2958

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The BMJ is launching a Christmas appeal this year and has chosen Médecins Sans Frontières as its charity. Details on how to give will be posted on bmj.com shortly. David Nott has kicked off the appeal by donating his fee for this article to the charity.

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