On Friday prof and I spent a tricky half hour debating whether to take a patient to theatre for a craniotomy. He had been stood on a two metre platform at work, adding caustic soda to a vat of boiling water. Unfortunately, but not unexpectedly, the resultant mix had erupted into his face, giving him 20% chemical burns, a horrific chemical burn to both eyes and causing him to fall on his head.
When he arrived with us three hours later he was comatose. He had been walking around and talking for an hour post injury, but then started fitting on his arrival at a rural clinic one hour later. He had been sedated then transferred here.
The eye injuries and burns, while tragic, were not immediately life-threatening. His story was however suggestive of an extra-dural haemoatoma, which would need immediate decompression. In the UK, in this situation, a CT scan gives a rapid and conclusive answer. Here, we do a clinical assessment and make a decision as best possible with what is available. We have not done a single craniotomy since I arrived, although we came close when we had a comatose 6 year old with a depressed skull fracture. He however woke up before I could get him to theatre - a near miss!
Unfortunately, one of the key parts of the clinical assessment of a head injur is the pupil reaction - something we did not have due to the ocular injury. We spent some time checking his reflexes and muscle tone, and response to painful stimuli. The initial conclusion was that he was hypertonic, but bilaterally so, and possibly still fitting. So, after a further dose of diazepam he was still unconscious but less stiff, and crucially the same on both sides. So no craniotomy indicated. We managed him lying on his side, hoped he did not have an unstable spinal injury and tried to stop him aspirating any vomit. He is now starting to wake up 24 hours later.
Being in the position, on an almost daily basis, of having to make critical decisions with minimal diagnostic support, has given me a new attitude and new set of skills in patient assessment. I am looking forward to having a CT scanner sat waiting to help me with the answer on my return, but I am also expecting to make much better use of my clinical skills before doing the scan!
Friday, 18 January 2013
Wednesday, 16 January 2013
Dogs and other creatures
You have already heard about and seen a picture of Tiger, the communal dog. However, he isn't the only dog around here. There are packs of them that wander around all day and all night. Some of them are friendlier than others. For a while Nat was the only one that complained of being attacked by dogs when alone - to the extent that she would only walk the long way back from our place if Will was away, because she was scared of the dog that loiters at one of the houses.
We mocked her mercilessly. Pretending that she was imagining the dogs and imagining being attacked. Then other people started to be chased and growled at aggressively. The mocking lessened. Finally, I was attacked. I was walking along minding my own business when one of the little sandy coloured dogs decided that I'd looked at him funny. He jumped up, growled at me, charged my leg with his mouth open, shutting it at the last second before head butting me instead. I started to walk the long way to Nat's house if I was alone...
The other endearing trait of the dogs is their howling. Normally at night just as you've managed to get to sleep. If it happens in the evening I've discovered that it's quite easy to stop. One night I was so annoyed I threw our door open and shouted out "I've got an idea, why don't you shut up?". There was silence and thereafter opening the door and shining the torch at them has the twin effect of getting them to be quiet and move away, so they are noisy somewhere else later in the night.
We were promised that the strays would be shot by the Police about 2 months ago. Nothing has happened on that front but someone has clearly taken some action because most of the strays are suddenly incredibly afraid of people, which means they haven't attacked anyone in a while, which is nice.
On the night of the chestnut roasting we had a new visitor. Julie, in the partial darkness, identified the dog as Tiger and invited him into the garden. This was Puppy. Puppy is about half the size of Tiger, plain sandy coloured (where Tiger is ginger and white) and has a very curly upright tail. We haven't yet worked out how Julie got them confused. Puppy is also incredibly timid, so shortly he left the garden.
The next time we saw him, Jamie, Julie and I were having sundowners on the field, sat on our blankets. Up came Puppy and decided that he wanted to be my friend especially. He demonstrated this by coming right up to me and sticking his muzzle in my Gin and Tonic. As Geoff's very allergic to dogs and I wanted my G&T without fleas in, he got short shrift. Julie was employed to stroke him and keep him at a distance. After half an hour her hand had turned black with dirt off his fur. We decided that stroking him was probably out of the question in future!
Now, I know that Katie will be reading this and getting cross about the fact I'm talking about domesticated animals. Tough! Subsequent to the sundowner, Puppy has been an occasional visitor at our house. During the day I let him lie in the sunshine on the warm concrete of our doorway. Sometimes, if he whimpers at me enough and sits on my feet, I'll stroke him (and then wash my hands about a hundred times).
Yesterday he was having a nap under our table when Tiger came in. Tiger and I have been having a small dispute, generally about the fact that Tiger pretends to like me when I have food for him but at all other times favours Gemma and then acts as if I haven't noticed. In response to this I've started pulling his ears and folding them one on top of the other, and pulling his tail when he heads under the table at dinner. This has so far only caused him to turn around and look at me severely, which is nice because he can be very vicious with people he doesn't like.
Anyhow, Tiger doesn't think that Puppy should be in our house so he came in to chase him out. After a while Puppy came back and curled up again. Then Tiger returned. This was repeated frequently. On one occasion, Tiger was spotted in our garden. All of a sudden his feet were up on the windowsill and his ears were pricked up as he looked in. The next thing we knew he was coming in through the door to chase Puppy out again.
Puppy is quite plucky, given that he keeps coming back, despite the aggressive jealousy of Tiger. I'm just not sure how long we will tolerate him for. He insists on being right next to any humans. So he followed Geoff to the shower yesterday and back afterwards, sitting on his feet at every opportunity. This might get a little tiresome!
The major new other creatures we have discovered of late are snails. Now the rains are here the snails have come out of hiding. They all have the pointy shells often associated with African snails. I'm a little worried about our veg patch but it seems to be holding up. The other night Will was looking out of our window with his powerful torch. "Errr, you might want to do something about this, I think your cabbages are under threat!" We gathered around him to see what he could see - a massive African land snail about 8 or 9 inches long in the shell right on the edge of the cabbages. Geoff was rapidly despatched with a plastic bag to facilitate the removal of said creature. He [the snail] has not been seen since.
There is also a new pet at the BLs [Nat and Will]. He's called Sprout and he's a baby, that's kept in a tupperware box in their kitchen. He's a chameleon (or if Geoff's telling you, he's a gecko :) ). Will has the care sheet for adults but this is very much a baby. It remains to be seen how well he will do!
We mocked her mercilessly. Pretending that she was imagining the dogs and imagining being attacked. Then other people started to be chased and growled at aggressively. The mocking lessened. Finally, I was attacked. I was walking along minding my own business when one of the little sandy coloured dogs decided that I'd looked at him funny. He jumped up, growled at me, charged my leg with his mouth open, shutting it at the last second before head butting me instead. I started to walk the long way to Nat's house if I was alone...
The other endearing trait of the dogs is their howling. Normally at night just as you've managed to get to sleep. If it happens in the evening I've discovered that it's quite easy to stop. One night I was so annoyed I threw our door open and shouted out "I've got an idea, why don't you shut up?". There was silence and thereafter opening the door and shining the torch at them has the twin effect of getting them to be quiet and move away, so they are noisy somewhere else later in the night.
We were promised that the strays would be shot by the Police about 2 months ago. Nothing has happened on that front but someone has clearly taken some action because most of the strays are suddenly incredibly afraid of people, which means they haven't attacked anyone in a while, which is nice.
On the night of the chestnut roasting we had a new visitor. Julie, in the partial darkness, identified the dog as Tiger and invited him into the garden. This was Puppy. Puppy is about half the size of Tiger, plain sandy coloured (where Tiger is ginger and white) and has a very curly upright tail. We haven't yet worked out how Julie got them confused. Puppy is also incredibly timid, so shortly he left the garden.
The next time we saw him, Jamie, Julie and I were having sundowners on the field, sat on our blankets. Up came Puppy and decided that he wanted to be my friend especially. He demonstrated this by coming right up to me and sticking his muzzle in my Gin and Tonic. As Geoff's very allergic to dogs and I wanted my G&T without fleas in, he got short shrift. Julie was employed to stroke him and keep him at a distance. After half an hour her hand had turned black with dirt off his fur. We decided that stroking him was probably out of the question in future!
Now, I know that Katie will be reading this and getting cross about the fact I'm talking about domesticated animals. Tough! Subsequent to the sundowner, Puppy has been an occasional visitor at our house. During the day I let him lie in the sunshine on the warm concrete of our doorway. Sometimes, if he whimpers at me enough and sits on my feet, I'll stroke him (and then wash my hands about a hundred times).
Yesterday he was having a nap under our table when Tiger came in. Tiger and I have been having a small dispute, generally about the fact that Tiger pretends to like me when I have food for him but at all other times favours Gemma and then acts as if I haven't noticed. In response to this I've started pulling his ears and folding them one on top of the other, and pulling his tail when he heads under the table at dinner. This has so far only caused him to turn around and look at me severely, which is nice because he can be very vicious with people he doesn't like.
Anyhow, Tiger doesn't think that Puppy should be in our house so he came in to chase him out. After a while Puppy came back and curled up again. Then Tiger returned. This was repeated frequently. On one occasion, Tiger was spotted in our garden. All of a sudden his feet were up on the windowsill and his ears were pricked up as he looked in. The next thing we knew he was coming in through the door to chase Puppy out again.
Puppy is quite plucky, given that he keeps coming back, despite the aggressive jealousy of Tiger. I'm just not sure how long we will tolerate him for. He insists on being right next to any humans. So he followed Geoff to the shower yesterday and back afterwards, sitting on his feet at every opportunity. This might get a little tiresome!
The major new other creatures we have discovered of late are snails. Now the rains are here the snails have come out of hiding. They all have the pointy shells often associated with African snails. I'm a little worried about our veg patch but it seems to be holding up. The other night Will was looking out of our window with his powerful torch. "Errr, you might want to do something about this, I think your cabbages are under threat!" We gathered around him to see what he could see - a massive African land snail about 8 or 9 inches long in the shell right on the edge of the cabbages. Geoff was rapidly despatched with a plastic bag to facilitate the removal of said creature. He [the snail] has not been seen since.
There is also a new pet at the BLs [Nat and Will]. He's called Sprout and he's a baby, that's kept in a tupperware box in their kitchen. He's a chameleon (or if Geoff's telling you, he's a gecko :) ). Will has the care sheet for adults but this is very much a baby. It remains to be seen how well he will do!
Monday, 14 January 2013
Breastfeeding
This might seem like an odd topic to select for its own blog post, but there is a good reason why I've chosen it.
In the UK, there is an ongoing debate about the acceptability of breastfeeding in public. Plenty of restaurants and pubs have been vilified in the press for refusing to let mothers breastfeed in the open areas, however discreetly. It seems to be an odd thing to quibble about - I've never really understood what the objections should be - done well, people barely notice. Banning it is effectively telling mothers they can't leave the house for 6 months without the hassle of expressing.
In Zambia, the view is much more liberal. There is no concern about breastfeeding, in fact I don't think there's anywhere or anytime when it's deemed unacceptable. And before any of you generate the naive notion that these ladies are doing the dance of the seven veils with a Chitenge, let me put you right. They aren't.
Most Zambian women, particularly the poor, do not wear bras. This and, we presume, multiple pregnancies from a young age combined with breastfeeding each child for more than 6 months (more on this later), mean that the women are able to articulate their breasts in a way that most British women would wince at. For example, it's perfectly possible, when wearing a polo shirt, to breastfeed your child without removing your top - just pull whichever one you want out through the slit at the neck and move the child in the Chitenge.
One evening I walked past a lady who had been doing this, but when the child had finished and she'd put them back on her back, she forgot to return the breast to the inside of her top. I didn't know what to do. I don't have the Nyanja to say 'Excuse me, Miss, but your boob appears to be hanging out' and I didn't know how she'd take it. I chose to walk on, hoping that someone else would mention it before long.
In fact, they are so comfortable with breastfeeding that they happily sort the child out whilst having a conversation with someone, even a stranger like me, without batting an eyelid at exposing the entire breast. I suppose this isn't that surprising in some respects, women on the wards are often half naked from the waist up, without seeming worried.
I don't know when they stop breastfeeding - I've seen quite large children still suckling. In OPD on one of my tours with new students, I saw a child of about 3 run across the floor to his mother, reach into her t shirt and grab her. She bent down happily to accommodate him as he stood on the floor in front of her. I was reminded slightly of Little Britain.
And it's not as if you get a respite after your last child. Grandmothers are frequently called upon to help out with the next generation. The Physiology of this is confusing to all of us. The Medics claim to have seen a grandmother produce milk on demand...
So what can we conclude. Part of the difference between the views is that in Zambia breasts aren't seen as sexual organs particularly. The men are much more interested in what a woman is like from navel to knee. Hence there is no embarrassment about public displays of breasts.
In the UK, this is not the case and therefore breastfeeding will always be emotive, as if the baby is interloping where it shouldn't be. This is also why there is a stigma around breastfeeding a child for too long - I imagine this will never change.
However, I think there is a happy middle ground that could be reached where new mothers wouldn't feel embarrassed or ashamed to feed their newborns in the natural way pretty much wherever they felt like it. As long as they didn't give any innocent bystanders an eyeful!
In the UK, there is an ongoing debate about the acceptability of breastfeeding in public. Plenty of restaurants and pubs have been vilified in the press for refusing to let mothers breastfeed in the open areas, however discreetly. It seems to be an odd thing to quibble about - I've never really understood what the objections should be - done well, people barely notice. Banning it is effectively telling mothers they can't leave the house for 6 months without the hassle of expressing.
In Zambia, the view is much more liberal. There is no concern about breastfeeding, in fact I don't think there's anywhere or anytime when it's deemed unacceptable. And before any of you generate the naive notion that these ladies are doing the dance of the seven veils with a Chitenge, let me put you right. They aren't.
Most Zambian women, particularly the poor, do not wear bras. This and, we presume, multiple pregnancies from a young age combined with breastfeeding each child for more than 6 months (more on this later), mean that the women are able to articulate their breasts in a way that most British women would wince at. For example, it's perfectly possible, when wearing a polo shirt, to breastfeed your child without removing your top - just pull whichever one you want out through the slit at the neck and move the child in the Chitenge.
One evening I walked past a lady who had been doing this, but when the child had finished and she'd put them back on her back, she forgot to return the breast to the inside of her top. I didn't know what to do. I don't have the Nyanja to say 'Excuse me, Miss, but your boob appears to be hanging out' and I didn't know how she'd take it. I chose to walk on, hoping that someone else would mention it before long.
In fact, they are so comfortable with breastfeeding that they happily sort the child out whilst having a conversation with someone, even a stranger like me, without batting an eyelid at exposing the entire breast. I suppose this isn't that surprising in some respects, women on the wards are often half naked from the waist up, without seeming worried.
I don't know when they stop breastfeeding - I've seen quite large children still suckling. In OPD on one of my tours with new students, I saw a child of about 3 run across the floor to his mother, reach into her t shirt and grab her. She bent down happily to accommodate him as he stood on the floor in front of her. I was reminded slightly of Little Britain.
And it's not as if you get a respite after your last child. Grandmothers are frequently called upon to help out with the next generation. The Physiology of this is confusing to all of us. The Medics claim to have seen a grandmother produce milk on demand...
So what can we conclude. Part of the difference between the views is that in Zambia breasts aren't seen as sexual organs particularly. The men are much more interested in what a woman is like from navel to knee. Hence there is no embarrassment about public displays of breasts.
In the UK, this is not the case and therefore breastfeeding will always be emotive, as if the baby is interloping where it shouldn't be. This is also why there is a stigma around breastfeeding a child for too long - I imagine this will never change.
However, I think there is a happy middle ground that could be reached where new mothers wouldn't feel embarrassed or ashamed to feed their newborns in the natural way pretty much wherever they felt like it. As long as they didn't give any innocent bystanders an eyeful!
Friday, 11 January 2013
STOP PRESS: SNAKE!!!!
Ever since Will pointed out that we could schedule blog posts, you might have noticed that they often pop up at regular intervals. This has been very useful but it has the drawback of not being particularly responsive. The post from today Geoff wrote a few days ago.
But something exciting has happened, and it's a Friday, so you get two posts today! How lucky!
Last night we were invited to Tiko for pre-dinner drinks to say goodbye to Claire and Dave who have been working there for 3 months. Geoff and I were asked to collect Will and meet Nat at the front of the hospital so we could walk over together. Will was in the middle of the washing up and said he'd meet us at the front door.
We went round the front and played with Tiger whilst we waited. Suddenly Geoff said 'Snake!' There in the tree by the gate was a black snake wrapped round a branch at just above head height. It was making its way down. We stood still about 5m away on the porch of the house and started shouting for Will. "SNAKE!' "WILL" 'CAMERA!' 'WILL!!!!!'. In hindsight, it probably wasn't sensible to yell snake, given that the locals tend to interpret that as a command to find a stick and kill it.
When he came to the door he was bemused. 'What are you two making so much noise about?' 'SNAKE!' [this isn't fear, it's that we know he loves them and wouldn't want to miss it!] 'Oh, I should get my camera!' Yes, that's what we were yelling.
Now, Will has a brilliant snake identifying App. You just have to know how many ventrals the snake has, which requires you to have the snake upside down and still long enough to count them. We can't think of any more useful App in the world. Anyway, invariably we ask Will for the identity of the snake.
He walked forward towards the tree. By this time the snake has clearly had enough of the yelling and the dog (which didn't notice him but ran under the tree 3 times) and is making its way back up. 'Bush snake?' suggests Will. 'Are you sure?' I say. Everyone tells us all snakes are bush snakes and the markings on this one don't look right to me.
'Um, no, actually, I think it's a black mamba.....' Geoff attempts to enter the house but the door is locked. I decide to stay still. Will withdraws. The snake doesn't seem to have noticed and is still making his way up into the higher branches of the tree. It is between 1.5m and 2m long. It's impressive to watch it moving between the branches, it has amazing poise. Then we remember that they can move along the ground with 2/3rds of their body off the ground.....
In case you've forgotten what I said about the mamba, they are one of the world's deadliest snakes. They are territorial and incredibly aggressive when cornered. They can move faster than a human [Correction: they can move at 10-12mph, which my brother claims is NOT faster than an able bodied human...] and one strike is more often than not deadly. The nearest anti-venom is in Johannesburg - we've discussed many times whether we think it's possible to keep someone alive using CPR long enough to get them there. We don't think we could. Sometimes they don't envenom, if they are feeling nice!
I remembered that a few weeks ago I was heading to see Will in the afternoon and there were two men at the bottom of this tree with a stick trying to kill a snake. I told them off and that the man that lived here liked snakes. He does and he wouldn't have wanted it dead, even if it was a mamba, but I have more sympathy for the men now.
We lost sight of it in the second tree, very high up in the branches.
Here's a shot that Will took. It's an ID shot, not a creative shot. And yes, there's no head in it [the mamba has a distinctive coffin shaped head - it wasn't as distinctive as I'd hoped!]. We won't mention it to Will again because when I made this comment yesterday he called me 'the pain that a Zebra feels when it's bitten on the bottom by a Tsetse fly' in Afrikaans.
To identify snakes you need the shape of the head and the scales. The mamba has very distinctive large scales - as seen here. If you want to give us an alternative identification (and in some respects we'd welcome that) please feel free :)
But something exciting has happened, and it's a Friday, so you get two posts today! How lucky!
Last night we were invited to Tiko for pre-dinner drinks to say goodbye to Claire and Dave who have been working there for 3 months. Geoff and I were asked to collect Will and meet Nat at the front of the hospital so we could walk over together. Will was in the middle of the washing up and said he'd meet us at the front door.
We went round the front and played with Tiger whilst we waited. Suddenly Geoff said 'Snake!' There in the tree by the gate was a black snake wrapped round a branch at just above head height. It was making its way down. We stood still about 5m away on the porch of the house and started shouting for Will. "SNAKE!' "WILL" 'CAMERA!' 'WILL!!!!!'. In hindsight, it probably wasn't sensible to yell snake, given that the locals tend to interpret that as a command to find a stick and kill it.
When he came to the door he was bemused. 'What are you two making so much noise about?' 'SNAKE!' [this isn't fear, it's that we know he loves them and wouldn't want to miss it!] 'Oh, I should get my camera!' Yes, that's what we were yelling.
Now, Will has a brilliant snake identifying App. You just have to know how many ventrals the snake has, which requires you to have the snake upside down and still long enough to count them. We can't think of any more useful App in the world. Anyway, invariably we ask Will for the identity of the snake.
He walked forward towards the tree. By this time the snake has clearly had enough of the yelling and the dog (which didn't notice him but ran under the tree 3 times) and is making its way back up. 'Bush snake?' suggests Will. 'Are you sure?' I say. Everyone tells us all snakes are bush snakes and the markings on this one don't look right to me.
'Um, no, actually, I think it's a black mamba.....' Geoff attempts to enter the house but the door is locked. I decide to stay still. Will withdraws. The snake doesn't seem to have noticed and is still making his way up into the higher branches of the tree. It is between 1.5m and 2m long. It's impressive to watch it moving between the branches, it has amazing poise. Then we remember that they can move along the ground with 2/3rds of their body off the ground.....
In case you've forgotten what I said about the mamba, they are one of the world's deadliest snakes. They are territorial and incredibly aggressive when cornered. They can move faster than a human [Correction: they can move at 10-12mph, which my brother claims is NOT faster than an able bodied human...] and one strike is more often than not deadly. The nearest anti-venom is in Johannesburg - we've discussed many times whether we think it's possible to keep someone alive using CPR long enough to get them there. We don't think we could. Sometimes they don't envenom, if they are feeling nice!
I remembered that a few weeks ago I was heading to see Will in the afternoon and there were two men at the bottom of this tree with a stick trying to kill a snake. I told them off and that the man that lived here liked snakes. He does and he wouldn't have wanted it dead, even if it was a mamba, but I have more sympathy for the men now.
We lost sight of it in the second tree, very high up in the branches.
Here's a shot that Will took. It's an ID shot, not a creative shot. And yes, there's no head in it [the mamba has a distinctive coffin shaped head - it wasn't as distinctive as I'd hoped!]. We won't mention it to Will again because when I made this comment yesterday he called me 'the pain that a Zebra feels when it's bitten on the bottom by a Tsetse fly' in Afrikaans.
To identify snakes you need the shape of the head and the scales. The mamba has very distinctive large scales - as seen here. If you want to give us an alternative identification (and in some respects we'd welcome that) please feel free :)
 |
| Mamba making its way down a branch |
Limb threatening injuries
I've been struggling to come up with a clinical topic for the blog, but a comment in the notes from one of the physiotherapists gave me an idea. It was "limb-threatening injury. High risk of significant contractures of elbow and shoulder". The patient is a 20 year old lady, who has a child of 6 months. She suffered a full thickness burn to her non-dominant arm, which was managed expectantly at another hospital for three weeks. As could have been predicted, the wound did not heal and she started to scar with her arm stuck straight at the elbow and in at her side. Since her arrival, we have excised the burn and grafted the arm. It was also splinted, but she removed it because of discomfort (twice) and so she is starting to develop more contractures.
Major limb threatening injuries are something we see quite commonly at SFH. They are either due to comminuted open fractures with significant tissue loss, massive soft tissue trauma or burns. The first two are normally due to traffic incidents. In the UK, I have had limited exposure to these injuries, as they are managed by teams of surgeons (plastic, orthopaedic and vascular) in tertiary centres, with most operations done by consultants. Open fractures are graded from 1 to 3, depending on the degree of soft tissue damage. Fresh grade 1 fractures can be cleaned, sutured, placed in plaster and given antibiotics. All others need cleaning, fixation (often externally) and sometimes skin flaps or grafts to cover the defect. Infected open fractures need external fixation and scrupulous wound management, as well as antibiotics.
What we are able to do here is more limited than at home, but still normally saves the limb. I was discussing with a visiting orthopaedic consultant from Addenbrooke's what he would do differently in the UK, as he operated on a comminuted open knee fracture. Interestingly, the only big differences were the need for vascular imaging to rule out an arterial injury, and intra-operative radiology. So, we have the majority of the kit needed to do things properly, and the skills (Prof is trained in trauma surgery), what often hampers us is the level of understanding in our referral centres, or even junior staff.
One of the things I have been trained in since arriving at SFH is application of external fixators, and I have now operated on quite a few open fractures. The very pleasing ones are those that come early, with limited infection or soft tissue loss, who can then be fixed and discharged with the fixator after a week or so. Others are more of a challenge. We have one young man in hospital at the moment, who had a huge devolving injury of his leg, with an open ankle fracture (following an assault). He was sutured and put in plaster by another hospital, and came here after two weeks, with a huge soft tissue defect and pus pouring out of his ankle. After two weeks of external fixations and wound care, we have now grafted his leg and expect to be able to put a flap on his ankle in the next month or so. What was very much a limb-threatening injury appears to be salvaged.
There is however a lot of dogma associated with open fracture management (and limb burns, which I will touch on later). One of our difficult patients at the moment presented with a fresh grade 1 (open) tibia fracture (it is in fact in four pieces), and the on call debrided the wound and placed it in plaster. Unfortunately, despite the instructions in the notes, and the assistant saying the fracture should be sutured, the wound was left open, with exposed fracture at the base. Essentially an iatrogenic grade 3 fracture. We then had to apply an external fixator and make a fasciocutaneous flap to cover the defect. When asked why he had ignored the departmental policy and written instructions, I was just told that open fractures should never be closed. The patient will however keep his leg, and regardless of how it was fixed, he is going to be a long time recovering (we are considering plating his tibia in the next few weeks).
We do have some failures. One recently discharged patient had an infected open ankle fracture sutured, and needed external fixation and a flap to save the leg. The fixator has just been removed (it became infected) and the fracture does not look well healed. He is however a very elderly man, so I suspect that having a leg that partly works is acceptable, and we are going to see how he does. We have also amputated a few terrible open fractures in the last few months, that for reasons of infection or vascular compromise were just not salvageable.
Returning to the first case, the burnt arm, I suspect she will always have a poorly functioning arm. Ideally, earlier grafting and splinting would have made things much better. The policy in a lot of hospitals of referring only when burns do not heal means we start trying to save the limb a step behind where we would like to be. Patients do seem more likely to remove dressings and splints than at home, so compliance is also a major issue. But, working within the limitations of our skills, and the available kit, I think we do alright!
Major limb threatening injuries are something we see quite commonly at SFH. They are either due to comminuted open fractures with significant tissue loss, massive soft tissue trauma or burns. The first two are normally due to traffic incidents. In the UK, I have had limited exposure to these injuries, as they are managed by teams of surgeons (plastic, orthopaedic and vascular) in tertiary centres, with most operations done by consultants. Open fractures are graded from 1 to 3, depending on the degree of soft tissue damage. Fresh grade 1 fractures can be cleaned, sutured, placed in plaster and given antibiotics. All others need cleaning, fixation (often externally) and sometimes skin flaps or grafts to cover the defect. Infected open fractures need external fixation and scrupulous wound management, as well as antibiotics.
What we are able to do here is more limited than at home, but still normally saves the limb. I was discussing with a visiting orthopaedic consultant from Addenbrooke's what he would do differently in the UK, as he operated on a comminuted open knee fracture. Interestingly, the only big differences were the need for vascular imaging to rule out an arterial injury, and intra-operative radiology. So, we have the majority of the kit needed to do things properly, and the skills (Prof is trained in trauma surgery), what often hampers us is the level of understanding in our referral centres, or even junior staff.
One of the things I have been trained in since arriving at SFH is application of external fixators, and I have now operated on quite a few open fractures. The very pleasing ones are those that come early, with limited infection or soft tissue loss, who can then be fixed and discharged with the fixator after a week or so. Others are more of a challenge. We have one young man in hospital at the moment, who had a huge devolving injury of his leg, with an open ankle fracture (following an assault). He was sutured and put in plaster by another hospital, and came here after two weeks, with a huge soft tissue defect and pus pouring out of his ankle. After two weeks of external fixations and wound care, we have now grafted his leg and expect to be able to put a flap on his ankle in the next month or so. What was very much a limb-threatening injury appears to be salvaged.
There is however a lot of dogma associated with open fracture management (and limb burns, which I will touch on later). One of our difficult patients at the moment presented with a fresh grade 1 (open) tibia fracture (it is in fact in four pieces), and the on call debrided the wound and placed it in plaster. Unfortunately, despite the instructions in the notes, and the assistant saying the fracture should be sutured, the wound was left open, with exposed fracture at the base. Essentially an iatrogenic grade 3 fracture. We then had to apply an external fixator and make a fasciocutaneous flap to cover the defect. When asked why he had ignored the departmental policy and written instructions, I was just told that open fractures should never be closed. The patient will however keep his leg, and regardless of how it was fixed, he is going to be a long time recovering (we are considering plating his tibia in the next few weeks).
We do have some failures. One recently discharged patient had an infected open ankle fracture sutured, and needed external fixation and a flap to save the leg. The fixator has just been removed (it became infected) and the fracture does not look well healed. He is however a very elderly man, so I suspect that having a leg that partly works is acceptable, and we are going to see how he does. We have also amputated a few terrible open fractures in the last few months, that for reasons of infection or vascular compromise were just not salvageable.
Returning to the first case, the burnt arm, I suspect she will always have a poorly functioning arm. Ideally, earlier grafting and splinting would have made things much better. The policy in a lot of hospitals of referring only when burns do not heal means we start trying to save the limb a step behind where we would like to be. Patients do seem more likely to remove dressings and splints than at home, so compliance is also a major issue. But, working within the limitations of our skills, and the available kit, I think we do alright!
Wednesday, 9 January 2013
Rainy season is accurately named!
We seem to have been waiting months for the rainy season to start.
We had gotten used through December to massive thunderstorms in the early evening after an increasingly hot day. This week, however, we seem to have got some UK weather. It's been grey and drizzly for most of the days so far. So I think we can safely say that it's finally arrived and will stay installed until we leave in February. Yesterday we had an episode of 'that real fine rain that soaks you right through' as Peter Kay described it.
The other weekend it was slightly different. Geoff and I were sat inside with the windows and doors open watching the grey clouds approaching from across the garden. Gemma had told us that one day she'd spotted it raining in the garden but not at the front of the house. We looked carefully and could see the same thing happening.
The clouds seem to have very distinct boundaries and the rain falls heavy and vertical so it's possible to see exactly where it starts and stops. Soon it was raining all around the house and the noise on the tin roof was almost deafening.
It got heavier and heavier. I was watching the tomato plants taking a battering. I thought I might take some photos but as I walked towards the cupboard the wind got up. All of a sudden rain was being blown in through the door and onto my laptop. I managed to slam it shut but there was already a puddle on the floor. The kitchen window had been ripped open from its partially shut position and now the deluge was coming in from there. Geoff was despatched out of the front door to push it shut. :) Definitely a man job, that one.
While this was happening we didn't notice that water was actually flowing in under the door and making its way into the cupboard where, amongst other things, the SLR camera is kept on the floor. Tasks were divided with Geoff sent to shut the remaining windows and check for leaks in the bathroom whilst I sorted out the new swimming pool.
I moved one of our foldable chairs out of the way only for an unseen glass bottle to fall from the armrest and promptly explode across the floor. Tiny shards of glass now covered the width of the bed and breadth of the living area.
Then, obviously, the lights went out.
After much cursing (although, notably, no blaming of Geoff who had put the bottle in that position) the situation seemed to be under control.
Half an hour later the sky cleared and the sun came out. Before long the ground looked dry. You'd never know there'd been a storm at all...
We had gotten used through December to massive thunderstorms in the early evening after an increasingly hot day. This week, however, we seem to have got some UK weather. It's been grey and drizzly for most of the days so far. So I think we can safely say that it's finally arrived and will stay installed until we leave in February. Yesterday we had an episode of 'that real fine rain that soaks you right through' as Peter Kay described it.
The other weekend it was slightly different. Geoff and I were sat inside with the windows and doors open watching the grey clouds approaching from across the garden. Gemma had told us that one day she'd spotted it raining in the garden but not at the front of the house. We looked carefully and could see the same thing happening.
The clouds seem to have very distinct boundaries and the rain falls heavy and vertical so it's possible to see exactly where it starts and stops. Soon it was raining all around the house and the noise on the tin roof was almost deafening.
It got heavier and heavier. I was watching the tomato plants taking a battering. I thought I might take some photos but as I walked towards the cupboard the wind got up. All of a sudden rain was being blown in through the door and onto my laptop. I managed to slam it shut but there was already a puddle on the floor. The kitchen window had been ripped open from its partially shut position and now the deluge was coming in from there. Geoff was despatched out of the front door to push it shut. :) Definitely a man job, that one.
While this was happening we didn't notice that water was actually flowing in under the door and making its way into the cupboard where, amongst other things, the SLR camera is kept on the floor. Tasks were divided with Geoff sent to shut the remaining windows and check for leaks in the bathroom whilst I sorted out the new swimming pool.
I moved one of our foldable chairs out of the way only for an unseen glass bottle to fall from the armrest and promptly explode across the floor. Tiny shards of glass now covered the width of the bed and breadth of the living area.
Then, obviously, the lights went out.
After much cursing (although, notably, no blaming of Geoff who had put the bottle in that position) the situation seemed to be under control.
Half an hour later the sky cleared and the sun came out. Before long the ground looked dry. You'd never know there'd been a storm at all...
Sunday, 6 January 2013
The beginning of the end?
It might seem a long time until the beginning of March and our return to our jobs, or at least my return as Geoff is technically unemployed from the end of our contract here, but we don't have many weeks left in Katete.
We intend to go travelling in Malawi for a week with Nat and Will, have a brief stop off in London and then go skiing for a week after we leave, so our departure is about a month away.
It is really starting to hit home now. In the past month we've had 4 new medics arrive and it's interesting to see how like us at the beginning they are. But their different personalities bring a different atmosphere to the Mess, the wards and the hospital. It feels a bit like the changing of the guard.
This week we are losing Fi and Rory on Thursday. It's strange to think that we've had our last weekend together. They have been giving away their household items to the new people and talking of their plans in London next weekend.
Today we did a large barbecue as part of the goodbye celebrations and it was a good opportunity to reminisce about our group experiences. We bought Will a bbq fan for Christmas so there was no need for Rory to take his top off to fan the coals today. We realised that he will probably never have to fan a fire pit again either because all our wood is too wet to do one this week.
Wednesday is the proper goodbye dinner at Phoebe's. We've requested flying ants and Nshima but the rest will be more Western food. Then I think we have to play pool with Rory and potentially go to Drums...
Drums is the nightclub in Katete. Since Geoff and I and Nat and Will don't really do nightclubs (I'm sure you are shocked to discover this), we've been kicking the can down the road. We promised Rory we'd go once in our time here. And we haven't been.
I had been mildly enthusiastic at some point until they came back from their second visit and described the lavatorial situation. That being that any sane person would do their business outside rather than go in the designated building. In the bush I'm fine with that, I quite enjoy it. In the middle of Katete, at night, surrounded by drunk people, dressed in trousers [the ladies appear just to pee with their legs open stood up in Chitenges (even sober during the day) - I know, I know] I can't think of much worse.
I've said I'll go if they catheterise me first...
We intend to go travelling in Malawi for a week with Nat and Will, have a brief stop off in London and then go skiing for a week after we leave, so our departure is about a month away.
It is really starting to hit home now. In the past month we've had 4 new medics arrive and it's interesting to see how like us at the beginning they are. But their different personalities bring a different atmosphere to the Mess, the wards and the hospital. It feels a bit like the changing of the guard.
This week we are losing Fi and Rory on Thursday. It's strange to think that we've had our last weekend together. They have been giving away their household items to the new people and talking of their plans in London next weekend.
Today we did a large barbecue as part of the goodbye celebrations and it was a good opportunity to reminisce about our group experiences. We bought Will a bbq fan for Christmas so there was no need for Rory to take his top off to fan the coals today. We realised that he will probably never have to fan a fire pit again either because all our wood is too wet to do one this week.
Wednesday is the proper goodbye dinner at Phoebe's. We've requested flying ants and Nshima but the rest will be more Western food. Then I think we have to play pool with Rory and potentially go to Drums...
Drums is the nightclub in Katete. Since Geoff and I and Nat and Will don't really do nightclubs (I'm sure you are shocked to discover this), we've been kicking the can down the road. We promised Rory we'd go once in our time here. And we haven't been.
I had been mildly enthusiastic at some point until they came back from their second visit and described the lavatorial situation. That being that any sane person would do their business outside rather than go in the designated building. In the bush I'm fine with that, I quite enjoy it. In the middle of Katete, at night, surrounded by drunk people, dressed in trousers [the ladies appear just to pee with their legs open stood up in Chitenges (even sober during the day) - I know, I know] I can't think of much worse.
I've said I'll go if they catheterise me first...
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