Today is the Wednesday Ortho clinic at Kijabe Hospital, and I decided to record each patient I consulted on before lunch time. I think this represents the type of patients we see, the types of problems they have, and the types of treatment required. I’m just going to go ahead and list them as I saw them. This was the first half of the day, the afternoon is kind of a blur, and I stopped recording the patients, but was pretty similar to the morning. I’ve left off most of the names for patient privacy, and shortened any names I’ve included.
Patient 1) A 6 year old girl who has been draining pus from her shoulder since she was 5 years old. She’s had a big surgery done, to remove the infected bone and replace it with bone from her leg. I took her splint off, she has a small area of pus draining, and the bone graft has not healed. Her arm is unstable, and still a little infected. She’s going to need another big surgery. Long term bone infection (chronic osteomyelitis, COM) is a plague in Africa. There is often no cure, and it cripples many people.
Patient 2) A 55 year old woman with back pain. She’s a farmer, which means she spends her day working the ground by hand, bent over from the waist. Her Xrays look fine. She needs ergonomic education and strengthening of her pelvic, stomach, and back muscles. We send her to physiotherapy for education, and give her some mild pain killers.
Patient 3) This is an older gentleman who fell and broke below his hip joint, a sub-trochanteric fracture. This is a difficult fracture with high complication rates. He had had a plate and screws put in, which had failed, and we place a type of nail. The fracture is healing very nicely, he’s walking without crutches. We’ll see him back in two months for new Xrays.
Patient 4) A 45 year old lady who was admitted two weeks ago for surgery for a hip fracture. The morning just before she had surgery, she suffered a stroke. She has mostly recovered, with just a little facial weakness remaining. But no one has determined the cause of her stroke: her blood pressure and cholesterol are normal. She still needs to have a heart test, and some blood clotting tests done. We can’t really do the surgery when she’s at high risk for another stroke, so we arrange to just see her back in a couple of weeks. Meanwhile, she has to live with a broken hip, using crutches and pain medications.
Patient 5) This is a 5 year old girl who broke her elbow and hand it pinned a few weeks ago. This is the same fracture which I had to fix on Jane several months ago. Her name is Amani Angel, which means peaceful angel. She is not a peaceful angel. From the moment I began to gently remove her ACE bandage, she belted out the most blood-curdling scream. We backed off, tried to console her, the little amani angel. Her mother did her best to reassure her. Amani wasn’t fighting us at all, she let us remove the dressings and splint without a struggle, but our eardrums payed the price. I quickly pulled the pins out, just with my fingers, as they slip out quite easily. The screaming increased in pitch for four or five seconds, then returned to baseline. She returned to her normal amani self the instant I walked out of the room. Her fracture is healing nicely, we’ll see her back in a few weeks for a check up Xray.
Patient 6) Our next patient is an 18 year old boy. Six weeks ago, he was playing soccer and was tackled from the side. His knee bent sideways with a loud crack. I saw him in casualty, where his leg was definitely at an unusual angle. Xrays showed that he had fractured his femur (thigh bone) just above the knee, through the growth plate. Thankfully, in an 18 year old, the growth plate is essentially done growing. We did a surgery on him where we straightened the fracture, and then inserted two screws through tiny incisions to hold everything in place.
To my surprise, he walked into clinic today with no splint, and no crutches! He wasn’t even limping. Xrays showed the fracture is healing very nicely, so we just asked him to stay out of soccer until we see him back for a new Xray in six weeks.
Patient 7) The next patient is a 48 year old lady who presents with excruciating back pain. Back pain is very common in every country. In Kenya, we always look for “red flags”. These are clinical signs or symptoms that the back pain is something other than the typical wear and tear. Red flags include excruciating pain, inability to get comfortable to sleep, fevers, draining wounds, weight loss, and weakness. This poor lady had many of these signs, indicating that she has something bad going on. She came in bearing Xrays and MRI that she’d had done in Nairobi. The Xrays showed destruction of the disc space between the 2nd and 3rd lumbar vertebrae in the low back. MRI showed the typical bone involvement and abscess of Tuberculosis of the spine. This plague from the middle ages is alive and well in Kenya. She’ll need one year of TB medications, and will likely need a spine fusion to help with the pain. She can be fit with a back brace for comfort and started on TB medications immediately.
Patient 8) The next lady was a bit of a breather from the severe problems we’d been seeing. She had some shoulder pain, called impingement syndrome, which generally responds to some rotator cuff strengthening exercises, some medications, and sometimes a cortisone shot. We started her on physio and gave her some anti-inflammatory meds, and can give her a shot if she doesn’t see improvement over the next month or so.
Patient 9) This 25 year old man had been knocked off when riding as a passenger on a piki (motorcycle). His elbow is broken and partially dislocated. He’s booked for surgery within the next few days, to put the joint back together. His elbow won’t be normal afterwards, but he should have good motion and very little pain.
Patient 10) The next patient is a 35 year old woman, who had stepped in a hole and broken her ankle about ten months ago. She had been placed in a cast, but still had a lot of pain and swelling, and her ankle is crooked. Xrays show that she had had a fracture and dislocation of her ankle, which should have had surgery immediately. At this point, the joint has degenerated into arthritis, and she will need to have her ankle fused. We talked about options with her, and she would like to go ahead with surgery. Our waiting list is about two months long for non-emergency cases, but she is willing to wait.
Patient 11) The next patient had some sort of bite on the back of his hand, and has a draining wound, and pain all the way up to his shoulder. As near as we can figure, he had a spider bite which is caused some skin death. We teach him wound care, put him on some antibiotics, and show him some exercises to avoid undue stiffness. We’ll see him back soon to see how the wound is healing.
Patient 12) The next patient is another child with heart breaking chronic osteomyelitis. She has had some surgeries to remove the infection, but still has a little pus coming out of her wounds. Thankfully, she has stayed in school through all of this. We change her antibiotics, and will see her back in a few weeks.
Patient 13) The next patient is a 10 year old boy who lives in a very remote, lawless part of Kenya where health care is not widely available. A year ago, he fell out of a tree and had severe hip pain, with shortening of the leg. He went to a traditional healer, but has had continued problems. His leg is about three inches short, and his hip is very painful to move and very stiff. Xray shows that he had dislocated his hip, it is still dislocated, and the “ball” is trying to wear a new “socket” in the side of his pelvis. Probably the only solution for him is to remove the hip joint, or to fuse it. We send him over to our brothers at the pediatric Cure hospital in the village for another opinion on this unsolvable problem
Patient 14) The next consult is a patient who is already in the hospital. He is a 75 year old man who was admitted to the internal medicine team about a month ago, in a coma from out of control diabetes. He was found later to have a hip fracture. He’s been in bed so long that he has some bed sores, but needs surgery for his broken hip. We devise a plan to get his hip fixed. He’s extremely anemic, so we arrange some blood transfusions for him to begin today.
Patient 15) The next patient has been shot in the humerus. The bones are nicely aligned, there is no infection, and the fracture should heal fine. We keep him in his plaster splint and will recheck xrays in a couple of weeks.
Patient 16) The next patient is a great guy who I have know for more than a year. He was in a terrible car wreck more than a year and a half ago. He had broken his arm (humerus), femur, and tibia. All of the surgeries had failed to heal his fractures, so we re-did them at Kijabe. He walked in without a limp or crutches today, all smiles. Xrays showed the leg fractures had healed completely, but his arm fracture had not, and the screws were beginning to fail. He will need another surgery, a nail in the humerus with a bone graft. He accepts this news without a blink, delighted to be up and walking.
At this point, I had to walk up to my house to get a little lunch, some coffee, and write some emails. One of the emails is finalizing arrangements for a VIP coming out from Nairobi to visit our little hospital (not John Kerry!). More about that tomorrow. Once the emails were done, back to clinic for the afternoon session. A very satisfying, if exhausting, day in clinic!