Posts Tagged With: trauma

French Toast and Trauma: Warning, Disturbing Image

Weekends are hard to predict around here.

I’m on trauma call for the hospital, so I need to stay close to home and close to my phone.  But beyond that, life goes on as usual.  Saturdays and Sunday are great family days, we try to sleep in, make coffee, and I’m on breakfast duty.

Saturday morning French Toast, Bacon, and Hot Coffee

Saturday morning French Toast, Bacon, and Hot Coffee

The kids get “screen time”:  Finding Nemo for Jane, Minecraft or reading books for Michael.  It’s the cold and rainy season, so a roaring fire and fuzzy PJ’s are mandatory.

Contented and Cozy

Content and Cozy

It’s great not having to rush off somewhere or have anything to do.  I make my way down to the hospital storage room to organize some donated equipment and get rid of a huge pile of useless junk.

The kids have friends within walking distance, RVA has high school rugby games to go watch, and dinner plans with great friends round out a perfect Saturday.  A peaceful start to the weekend.

Organizing the Store Room

Organizing the Store Room

Sunday is another story.  My phone jars me out of a sound sleep, the screen tells me it is the ortho resident calling.  I don’t really know what time it is, I just know it’s dark.

“28 year old guy on a piki (motorcycle), hit by a bus about 4 o’clock this morning.  Pelvic fracture, bad open floating knee.  Has had 4 units of blood, his BP is 100/50, and we’re on our way to theatre. His Hemoglobin level is 5 after the third unit of blood”  To translate, this man is bleeding to death, he has already lost at least two thirds of his blood volume.  Only healthy young people survive such blood loss, but they can die very quickly once their ability to compensate is overwhelmed.

Okay, I’m awake now.  I volley back some questions:  is the pelvic fracture stabilized with a binder, does he have two IV’s flowing wide open,  is more blood available, is he alert, can you feel a pulse in his leg, have antibiotics been started, has he gotten a tetanus shot, any chest or abdominal trauma, has his c-spine been cleared?

Yes, yes, yes, yes….The systems have worked, protocols have been followed, and this young man is going to have the best chance he can at survival and keeping his leg.  I’d like to repeat that sentence 10 more times, because it is amazing.  At this little hospital clinging to a muddy hillside in rural Kenya, this patient is receiving world class trauma care.  This is all down to the excellent work of the junior residents who met this man in the emergency department.  We don’t have a sophisticated lab to know his acid-base balance, we don’t have invasive monitoring to know his exact fluid resuscitation status, but within our abilities, every possible thing has been done, and is being done, to save this man’s life and limb.  In medical parlance, we move into “damage control” surgery.

The goal of damage control surgery is to stabilize the patient, quickly clean wounds, stop bleeding, and  get him into the expert hands of the intensive care unit doctors.  Damage control does not involve meticulous repair of wounds or fractures, just quickly trying to move him out of a life-threatening situation.

I gulp down a cup of instant coffee to clear my head and walk into the pink sky of the breaking dawn and down to the operating room.  The patient is just being wheeled into theatre, and I introduce myself and talk to him, in as reassuring tones as I can, about his injuries.  I’ve had more than one patient here with these same injuries never wake up from surgery, but he doesn’t need to know that right now.  “Your blood pressure has stabilized, things are looking good, we’re going to clean up your wounds and begin stabilizing your broken bones.”

With that, the nurse anesthetist gets him off to sleep while we stabilize his neck.  He hasn’t yet gotten an Xray of his neck, and has no pain there, but could easily have a broken neck and not know it.  The pelvic and limb fractures are painful enough to mask the pain of other injuries, so we always assume the spine is broken until proven otherwise.

The leg looks bad.  The thigh bone (femur) is broken and sticking out the front.  A large segment of the tibia bone is missing beneath the knee, and there is a clot of blood behind the knee.  Through my gloves, I can feel a pulse behind his knee, so we know the main artery to his leg is intact.  With a doppler probe, we can see that he has good blood supply to his foot.  So the leg is probably salvageable. But that clot behind the knee looks ominous.  We leave it alone, to be looked at more carefully a bit later.   Before he went to sleep, we had tested his ability to move and feel his toes, and this was normal.  Some reasons for optimism.  But the clot worries me.

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Floating Knee:  Open Fractures of the Femur and Tibia

Floating Knee: Open Fractures of the Femur and Tibia

We wash debris, paint chips, gravel, sand, and pieces of his trousers out of the wounds.  The fractured ends of the bones are tattooed blue from the paint on the bumper of the bus.  We meticulously clean everything, excising dead tissue, until the wounds look clean.  The residents and I install an external fixator, a stabilizing device which uses pins inserted into the bone to attach to a carbon graphite frame.  This can be applied in a matter of minutes, from his upper thigh to just above the ankle, to provide some stability to the leg.

The patient is getting cold.  Hypothermia, or below normal body temperature, is a common and ominous sign in severe trauma.  We get hot water bottles and blankets to cover every square inch of the patient that is not being operated on.  A cold patient can have severe metabolic disruption, including losing the ability to clot his blood.  This can be irreversible and fatal in a severely injured patient.  We turn the room temperature up to 86 degrees Fahrenheit.  While garbed in hats, masks, gowns, and lead vests, this becomes very uncomfortable, but is standard trauma protocol.

The wounds are clean, the fractures stabilized, and now it is time to go back and look at that clot.  I carefully place retractors to hold the surrounding tissues out of the way, and gently remove the clotted blood.  Before the case started, I had insisted that everyone in the room was wearing eye protection.  And this was why.  As I removed the clot, bright red blood began spraying out of the wound.  We had found the reason his hemoglobin blood levels were so low.  As the bumper of the bus hit his leg, one of the bone fragments had torn a hole in an artery in the back of his leg.  Gentle fingertip pressure stopped the bleeding, and we called for the talented general surgeon, Dr. Jack Baraza.

Jack was waiting in the wings, and quickly arrived to calmly explore the vascular injury.  There are three vessels which supply blood to the lower leg, and two were still intact.  So the repair was a simple matter of isolating and tying sutures around the offending blood vessel.  We rechecked the blood supply to the foot, and after a few tense moments, were rewarded with pink toes and a visible pulse on the doppler ultrasound screen.

Dr. Baraza checking the blood supply to the foot

Dr. Baraza checking the blood supply to the foot

Thick dressings are applied, a plaster splint reinforces the external fixator, some other wounds are quickly sutured, and the patient is ready for transport to the ICU.  He has a long and difficult struggle ahead of him.  The next 48 hours will show us how much reserve he has left.  As he stabilizes, we can begin to plan reconstructive surgeries to fix his pelvic and femur fractures, and restore the bone missing from his leg.

I walk back home to an empty house.  Ann and the kids are enjoying Mother’s Day by going on a hike at Crescent Island with some friends, so I have some breakfast and get ready for a nap.

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Day 4….Some days are better than others

As I sat down to write this, my phone rang.  It was the excellent resident I’m currently working with, calling with bad news.  He had brought our patient from Sunday, the one with the terrible leg infection, back to theatre to wash out the infection again.  Instead of finding the leg improving, he found toes turning black, and the muscles dying.  We got to Kamau too late.  The infection had gone too far.  This young man is going to need an amputation.

I can feel the resentment build:  why did this have to happen?  It wasn’t a complex problem: with some basic surgical care from the outset, he could be planning his recovery, this episode soon relegated to a painful memory and tales to tell his children and grandchildren.  Instead, he will be an amputee, in a country which doesn’t look kindly on disability.  Here we have no “Kenyans with Disabilities Act” to put in sidewalk ramps, require accessible public transport, or prevent employment discrimination.  Disability is sometimes viewed as a curse, creating fear, suspicion.  He will have some difficulty finding and affording a good prosthesis.  This is a huge setback for his life.

If this were an isolated instance, it would be simply frustrating.  But it is a regular occurrence, even here in Kenya, one of the more developed countries in sub-Saharan Africa.  I’ve been to countries where things are much worse, where there is simply no hope for patients with significant injuries.  The suffering across this continent is unimaginable.

There’s a lot of people working on this problem.  My Notre Dame classmate and roommate from medical school, John Meara, has risen to the highest echelons of the academic world, and is spearheading the Lancet Commission.  The Lancet, one of the oldest and most prestigious medical journals in the world, has decided to undertake a major project, looking at the effect of this severe lack of surgical capacity in the developing world.  The governing body of the World Health Organization meets in May and will pass a resolution declaring basic surgical care a right, much like access to clean water, food, security, and vaccines.  This is a watershed moment for the billions of people suffering worldwide from lack of access to adequate surgical care.

In our lifetimes, this problem will be reversed, and severe lack of surgical capacity will go the way of smallpox and polio.  But that doesn’t help Kamau today.

Our first patient for the day, a young man in a car wreck, was due to have his hip socket reconstructed after a fracture-dislocation of his hip.  Unfortunately, due to a scheduling error, we had to re-schedule his surgery for Thursday.

Our next patient was due for wrist reconstruction after a mangling injury a year ago when his van rolled over as his arm was out the window.  As we were preparing him for surgery, I pressed gently on a little opening in his arm.   To my surprise, a 3/4 inch seed pod popped out, followed by pus.  Apparently, despite multiple surgeries at two excellent hospitals in Tanzania and Nairobi, this remnant from his roadside injury had hidden inside his arm for a year.  It decided to work its way out on the day this patient was finally scheduled for his reconstructive surgery.  We cleaned out the infection and took him to the ward for intravenous antibiotics.

The third patient today was a middle aged lady who had fallen down some stairs, shattering her wrist.  She was scheduled for a combination of plating and external fixation today.  Though she has a history of hypertension (high blood pressure), she has been well controlled by medications.  Until she got onto the operating table.  Her blood pressure shot up to a dangerous 200/100, and persisted despite intravenous anxiety and blood pressure medications.  Surgery cancelled.

Next up, a two year old boy who fell down some stairs, hyper-extending his elbow to the point where the elbow broke just above the joint.  Jane had this same injury just last November.  The treatment is a surgery where the bones are manipulated back into position, and then held there with two pins introduced through the skin into the bone using video xray.  This went flawlessly, all the equipment worked perfectly, and he should be fine.  Finally, we accomplished something for the day.

Our last patient was the disastrous Kamau, wrapping up an all-too-typical day in the battle against trauma in Africa.  When he wakes up, we’ll need to give him the bad news and obtain consent for amputation.

In the big picture, I know progress is being made, systems are being formed, surgeons are being trained, the John Meara’s of the world are pushing global organizations to wake up to this unseen epidemic.  But day to day, my picture isn’t that big.  My picture is the men, women, and children in my clinics and theatres who suffer agony and disability from lack of safe roads, safe drivers, and access to safe surgical care.  Though we’re too late for Kamau, my prayer is that his children will live in a world with less suffering.

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