Clinical Digest1

Clinical Digest: Friday 19/2/10
Last week was my settling in week at Ntcheu, where I was meant to familiarise myself with the surroundings and with the hospital. I did a fair bit of the latter, without getting too involved. I still managed to get a good glimpse at the kind of orthopaedic case mix I’ll be encountering. I spent 4 half days with a very experienced clinical officer, whom I can only liken to a senior staff grade in the UK- doomed to never be a consultant somehow. His knowledge is extensive and he even appears overqualified for this post, the main obstacle to his exercising of his skills being limitation of equipment. I found it hard to add to his practice in these 4 sessions as he really knew how to juggle this massive workload and the scarcity of resources, so as to maximise his output. Say he decided to spend some more time on one patient to treat him/her marginally better, the direct result would be some 5 other people potentially missing out on the most basic treatment. I do hope to be able to take some of the pressure off his shoulders during my stay here but also to refine it and work on this refinement being maintained.
In terms of some interesting cases I saw, there was one in particular which I had no clue how to tackle. This infant came in with what appeared like a congenital dislocation of the knee (which was hyperextended to his shoulder at birth) and now recurrently adopts the same position with the minimal effort. The hips were fine. I couldn’t work out if this would be a self limiting problem or lead to some chronic disability- which could potentially be reversed by a very simple intervention like some splint or taping. In the end, we (or rather they) taped his knee in partial flexion for 6weeks and hoped for the better. I shall try and find a more scientific answer to this problem in the meantime. Any ideas from my audience are very welcome as my wealth of orthopaedic references here is limited (baggage restrictions oblige).
Two other cases I helped in were interestingly both knees again. One was a kid with a spontaneous effusion that started 6months ago and been aspirated twice already (but never cultured). So I aspirated it again and requested cultures this time, thinking TB/osteomyelitis quite high. Early results are negative, but we’re still waiting enrichment. The second knee was on a HIV+ patient with no history of trauma or systemic illness. He was not on ART but didn’t show any sign of AIDS. Anyway his knee grew Staph and we’re treating him. Both cases were really useful for me to get into another role I really want to develop here, which is that of a trainor. I used these first opportunities to teach the students and medical assistants about a few dos and don’ts of the procedure, especially the importance of aseptic no-touch technique (ANTT). At the moment however, it’s funny how it’s actually me who feel more like the student learning from them the way things are done in a context they’re much more familiar with. I shall endeavour to turn this into a mutual learning curve as time goes by.
As for operations, I stood in twice to watch operations beings performed, really fluently, by clinical officers, from the operating surgeon to the anaesthetist. There were two uncomplicated Caesareans (breech and cord delivery) and on another occasion, I saw an ERPC (not to be confused with an ERCP!). That is one grubby operation I really don’t look forward to being in charge of during my stint at Ntcheu.