FEB-A-15
WE FIND OURSELVES ALONE ON THE BUSY
AFTERNOON OF THE FIRST WEEKDAY OF A NEW WEEK,
WITHOUT ANOTHER DOCTOR OR EVEN NURSE IN
HARGEISA GROUP HOSPITAL;
THE CASUALTY ADMISSIONS OF THE DAY BEGIN
WITH A LETHAL ACCIDENT VICTIM AND END
WITH A BADLY SHATTERED OPEN TIB/FIB
FRACTURE OF THE RIGHT LEG IN AN EIGHT-YEAR-OLD GIRL, BEFORE WE ADJOURN TO THE
HOTEL MANSOOR
FOR MY FIRST SUCCESSFUL EMAILING
ON THE SECOND PASS
February 7, 2004
The first thing we saw on rounds this morning was a patient being gently trundled along on a gurney, with a lot of blood spattered all around on the gown that also covered here face. This is not unusual here for a person who is ill, since there are aggressive flies that swarm around the sick in the hospital wards and have the odd habit of perching nonchalantly on one’s eyes and near them. So, it is frequently the case that someone might sleep with this “headnet equivalent.” I was further convinced, since they were moving very slowly and cautiously to avoid excess jostling and injury or pain to the person on the gurney with both uneven hard tires on wheels and the rutted dirt incline was also rough. So, after we were finished with one ward, I suggested to Jay, who sent in his matching list to the ERAS (Electronic Residency Application System) to match in an emergency medicine program, that he go check out what the status of this trauma might be. He was back quickly, but I did not talk with him until after the next ward, when I asked about the trauma. He said “Deceased.” The patient was taken to the Casualty Department of the central hospital in town, only to be seen by whomever was there this morning. Who that “whomever” might be, it was NOT a doctor of even a nurse, since there were none at the beginning of the day (eight o’clock) except the director, Dr. Vaasin and he was with us. There was not even a nurse by 9:00 AM, and by noon those same two categories were absent again. So, 350 patients had to fend for themselves with whatever relatives or friends they could induce to bring them food and warehouse them while not much of any kind of care plan was taking place. They are in no hurry to get out, since we saw a few of the orthopedic patients who had been present for over a year. But remarkably little progress in anything but formation of pus had occurred within those wards, not remarkably different than the Crimean War Nightingale Wards after which this pavilion style hospital was designed by then recluse public health power Florence Nightingale
We conducted a busy clinic seeing scores of patients in two teams with their treatments being immediately dispensed to them from our own stock. The diagnoses included a patented with amebic colitis and amebiasis of the liver, a woman with shigellosis, who could not be admitted since she had a newborn daughter left at home who would need her services in very shortly spaced intervals. We had both rehydration salts and the right antibiotic, a quinolone, but she could not hold anything down, so we also sent her to the local chemist to pick up an injection to assist her with her nausea. We saw a number of tropical diseases, TB, STD’s and parasitic infestations and fewer but still present were the GERD and osteoarthritic degenerative joint disease that are most of the Himalayan patients. We had two cases of schistosomiasis, many of worms, and several little children with both pneumonia and ear infections. When we had completed the long queue (which is getting longer each day by word of mouth as we are known to be here—so much for our hotel’s assistant manger Abdhi who had infected the eager threesome students with the suggestion to solicit patients for operations they could do by advertising “Free operations by a US surgical team” on Radio Somaliland. In the crush of bodies to be flung at us if that were to occur, they would arrive to find no one at home. Dr. Vaasin would be left holding the bag, with a lot of very weary poor people who had traveled long distances to sleep against the locked gates of the hospital to be present early for their operating priority. That is exactly what happened to a team of four British surgeons who had to retreat out the back way leaving very infuriated potential patients whose hopes had been buoyed by the announcement. The bush telegraph is working over a long range and intensively enough already.
TRYING TO LEAVE THE HOSPITAL IN THE
AFTERNOON,
AS EVERYONE ELSE HAD DONE ALREADY,
“WHEN OUR WORK IS DONE”
AND THE INEVITABLE CRUNCH CAPTURES US
We had finished our clinic including the stragglers and the last personnel who had seen we were still present and came in for treatment on their own way out from their day which seemed to be over by noon, and Essa, our driver, was standing by to take us back to the Monsoor for lunch. The assumption had been that we would be working no longer than the other personnel, who had all gone. The students were feeling much better, since, although they had not operated on this day when no elective cases had been booked, they had worked in a busy clinic and had cleared a high volume of outpatients as well as a review of the newest and sicker inpatients. In a habit they will soon learn to avoid if they will ever hope to have a home life, they decided to go back and check on a few leftover details. I explained the “Tar Baby” syndrome, in walking casually into the Emergency Room—literally, that is all that is there---a room—and getting stuck by whatever one attempts to extricate oneself from, since there will always be several problems that require nothing more than survival, i. e. the passage of lifetime.
Kevin was surprised by my use of the term since he had thought that “Tar Baby” was a pejorative term for an African. I had to explain the Uncle Remus folk tale, since I had been fascinated in my early career on a remote mission in Nigeria that I heard what were almost identical nursery stories of the Uncle Remus type from Africans who had had little previous contact with Europeans, usually Brits, and none of them likely to know what I had thought were quintessentially American, often Southern, folk tales. It turns out, of course, that the oral tales were passed in the other direction, and that what I knew as American folk culture were tales transplanted from Africa with the slaves who had passed them on in traditional wisdom, with a few of the animals changing speices, since the American Southerner might not know Br’er Fox if he were called a jackal or hyena. I explained to Kevin that Br’er rabbit was proud of his standing, and could not take being ignored by an unusual problem confronting him, so he got involved and could not extricate himself once he had made contact, and wound up inextricably stuck to Tar Baby.
TAR BABY ARRIVES AS WE WERE IN THE
PROCESS
OF LEAVING, AND THE EMERGENCY TEAM
SWINGS
INTO ORTHOPEDIC ACTION
It was almost 1:00 PM when we were going over to where Essa had left the pickup truck for our ride back, when Jay ran back with the good news that there was a real trauma in the Emergency “Room.” Tar Baby had arrived in the form of an eight-year-old girl who was screaming in pain with her right leg dangling off at a right angle below an open wound. She had no need of an X-Ray, since she had the ends of both bones of the mid-shaft of her right tibia and fibula poking through the broken skin. This was not a day for lunch.
With no meds in the ER, Juan got out an Oxycodone tablet and crushed it in a gauze sponge and tried to suspend the powdery bits in the last few gulps of his “Hargeisa Mineral Water” bottle. This was the analgesia for the young girl whose mother sat patiently with her. Some of the same water from the water bottles we had carried from the hotel was used to dilute iodophor solution (the IV saline is too precious to waste as an irrigant), and Kevin syringed the solution through the open wound to irrigate out whatever contamination might be trapped inside the fracture. Jay held the foot, still in the right angle to the right of the leg, as we had checked to see that in that position she still had a pulse in it, and it had remained warm, and appeared to have sensation, although movement, of course, had been interrupted at the mid leg. Two of the attendants set about wrapping a piece of a cardboard box as a posterior splint. I had suggested that we should use a plaster splint to make a “trough” that could keep her ankle in a right angle with the toes pointing forward, with limb length the same, as long as we could be assured that the pulses remained after she was “reduced”, i. e. rotated back to face the toes forward. As long as she had a viable foot, we could continue the cleaning of the wound and making the plaster posterior splint, without emergently seeing if re-aligning the foot made any difference in restoring circulation.
I had seen plaster of Paris rolls on the Pharmacy shelf, but the pharmacy was locked and there was no one around who could retrieve it, since most all personnel had gone for the day. Essa, who had been ready to take us back, had gone when he had realized that we would be trapped here for a while. Somehow, the plaster was retrieved, and a posterior splint was made, when I realized that the “somehow” was the return of Dr. Vaasin, the Director, the one person who can be counted on to put in extended hours. He came by, and in a quick maneuver, reduced the child’s leg, after which she still had a pulse and was much more comfortable without the torn periosteum edges being poked by the bone fragments. I suggested they give tetanus toxoid, but there was none, so we used our best antibiotics, the third generation cephalosporins we had brought in good quantity to get her started on coverage against the inevitable osteomyelitis that she is doomed to develop in her prolonged hospital stay next to all the other draining wounds of infected bones on the ward. She would be a good candidate for one of the external fixators devices, much later, if an elective operation could be planned and the materials gathered for her. But, for now, she is started on the same long hospital course that the other slowly knitting bones are doing in a crowded ward.
This was a good exercise in emergency room function of stabilizing open fractures after cleaning them, making sure that they had no neurovascular compromise, and to further illustrate the point that the purpose of the lower extremity is STABILITY—and that we wanted to minimize the chances of a non-union of this mid-leg open fracture in a young girl. After all, “Ortho Pedics” means “Straight Child” and our initial handling of her open fracture should minimize limb loss immediately and in the longer term, instability of an extremity that should be able to return to weight-bearing.
We had missed one “window of opportunity”, Essa and the vehicle were gone and it was now closing in on 4:30 PM, too late for lunch even if we could get back to the Monsoor. But, we had opened another one, and this young girl will eventually be better off for our presence here. I noted a bit of reality returning however, when finally we got re-connected with Essa and the pickup truck and had all gathered to make another attempt at departure. I said to Jay, are you sure you might not want to take one more check on the ER, and let them know you may be available on call for the next evening and night shifts? “No, I have had enough for the day.” We might be missing another Tar Baby.