Monthly Archives: February 2013

Damage Control

The road above Kijabe village, the A104,  is a major African trucking route.  From the port on the Indian Ocean at Mombasa, the highway climbs to over 8000 feet before descending into the Great Rift Valley, and on to central Africa.  The highway is an artery for commerce, for transport, and for families traveling to and from the sprawling capital city of Nairobi.

We travel this road frequently, but always with an ache of anxiety.  Huge buses and lorries mix with erratically driven matatu packed with passengers, all in a winner takes all game of chicken.  Frantic passing, sometimes three or four abreast on a two lane highway, dodging pedestrians, bicycles, and donkey carts.  Sooner or later, Pauli’s exclusion principle wins out, as two objects try to occupy the same space at the same time.  Unfortunately, those objects contain people.  People with hopes, with daughters, with husbands.

There’s a branch of orthopaedic surgery, coldly labelled “damage control orthopaedics”, or DCO.  DCO refers to treating patients in the quickest, least invasive, but satisfactory method, when the patient is so severely injured that he or she wouldn’t survive the full repair ImageImageof their injuries.  The idea is to stop the damage, get the patient from the operating theatre to the intensive care unit, and hope they live to eventually have their injuries definitively treated.  DCO isn’t pretty or elegant, it’s doing the best you can in an awful situation, trying to save the patient”s life until they’re stable enough to be treated definitively.

Because Kijabe Hospital sits just three miles below this major highway, we sometimes experience “mass casualties.”  Hospitals in the US are required to occasionally stage mock mass casualties, to see how their systems hold up under extraordinary conditions.  The hospital here doesn’t stage drills, as they intermittently see 10 or 20 badly injured patients appear from the highway above.  Today was one such day.

I don’t have all the details, but a long funeral procession was making it’s way along the highway when one of the huge trans-national lorries veered into the line of cars carrying the family members of the deceased.  The people in the cars in back watched in horror as the truck plowed into and over the cars in the front of the possession.  When everything finally came to a standstill, a passing flatbed truck stopped, all of the bodies, living and dead, were put on the flatbed, and bounced down the bumpy mountain road to Kijabe’s tiny emergency room.

Kijabe is a rural African hospital.  It can take hours to get a simple xray or blood test done.   But when multiple injured patients arrive, everyone springs into action.  I have never seen such a dedicated, selfless, efficient team of individuals work so seamlessly for a common purpose.

As one of the trauma consultants, my job is to find a patient, identify their injuries, order appropriate tests, and work with the other consultants on triaging the most severely injured patients to the theatre.  This all happens with amazing speed and cooperation.  The eight operating theatres are cleared as quickly as possible, and the injured patients are whisked away in order of injury severity.

I found myself coordinating the care of four different patients, finding surgeons who would stop bleeding, stabilize fractures, suture wounds, apply bandages.  When things seemed somewhat under control, a 38 year old woman, Rhonda,  was wheeled into Theatre One with severe injuries to both legs.  Her blood pressure was low, her heart rate high, and she had no blood flow to one foot.  No xrays had been done yet,Image but examination showed that both femurs (thigh bones) were shattered, and on one side, sticking out.  Both knee joints were cut open, with one knee cap broken and hanging out of the wound.  On the other side, the foot had a large laceration, and we couldn’t find a pulse to indicate any blood flow to the foot.  Time for DCO.  Quick stabilization of both femurs with a minimally invasive device known as an external fixator, thorough washing and cleaning of all open wounds, blood transfusions are flowing, and Doppler ultrasound now shows feeble but adequate blood flow to the foot.  Things are looking up.  We wheeled her to the recovery room, and prepared for the next surgery.

Ten minutes later, a nurse came up and spoke in the polite, quiet, Kenyan way:  “We are coding your patient.”  You’ve seen “Codes” on TV shows:  pushing drugs through the IV, chest compressions, the defibrillator shocking the patient.  A code means that the patient’s heart has stopped beating, they are, at least for the moment, dead.  In a young person who was healthy only a few hours before, codes are taken to every extreme, until no hope is left.  Rhonda underwent every intervention possible, to no avail, and died after surgery.

I never really met Rhonda.  She was conscious before surgery, but I had been with other patients.  I met her in theatre one, after she was under anesthesia, and a surgeon was needed to treat her injuries.  I only got to know anything about her after she died.

The funeral procession was for her cousin.  As I met Rhonda’s husband and brother, to tell them that she had died, I learned that Rhonda’s daughter had died at the scene, and that her husband had witnessed the crash from a car further back in the procession.

Damage control.  How much suffering is possible?  How can a man continue to exist, how can his heart and lungs keep functioning, how can he continue to stand, how can his mind maintain a grasp on sanity, on a day like this?

I’m surrounded by men and women of great faith and grace.  Fortunately, a Kenyan friend and colleague was by my side and helped me break this news to the family.  In the end, we wound up praying with this family, they thanked us for doing all we could, and they asked that God would bless us.

Though I sometimes feel like I’m fitting in here, starting to understand things, learning a little Swahili, on days like this, I realize I can never know what it’s like.  If this accident happened in the US or England, it would make global news.  Here, it might make the Nairobi newspapers.  And this raises a paradox which is hard to understand:  Rhonda’s family blessed me, wished me well, thanked me for doing everything I could.  When suffering, death, malnutrition and AIDS are part of your daily reality, people draw closer to God, are more aware of His love, and are more willing to extend this grace to others.  I don’t deserve the kind words and blessing of Rhonda’s family, they deserve mine.

“Come to me, all you who are weary and burdened, and I will give you rest.  Take my yoke upon you and learn from me, for I am gentle and humble in heart, and you will find rest for your souls.”  Matthew 11:28-29

Rhonda’s husband and brother are weary and burdened beyond reason tonight, but they take Jesus’ words seriously.  In the midst of suffering, they find rest for their souls in the gentleness and humility of a man who lived 2000 years ago.  Tonight, I’m thankful for my family tucked safely into their beds, for the people of great faith who surround me, and for the blessings of Rhonda’s husband and brother.

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