Clinical Digest10

I realise I haven’t managed to enter details of my clinical work for quite a while on here. That was not purely out of fear of alienating my non-medical audience (as I’m told the medical jargon does interest the wider public too- hence the popularity of medical sitcoms!), but also due to the intensity of my life at and outside work recently. Hence I’ve been saving up the stories to deliver them in one package...

Man off the street
This case provided so many windows into the realities of working in the Malawian health care setting that I wish I had encountered it earlier and set the picture for you much right then on that subject. The man was a 60 odd year old who had been on our wards for some time under the general clinicians with some poorly healing leg wounds. Unfortunately he also suffers from an undiagnosed psychiatric illness. As a result he has also been abandoned by his family and community and ended up in the hospital without a guardian. This usually is a non-starter here. The patient has no one to assist him with self-care as the staff manning the ward are usually too busy to add that job to their list. Hence these patients invariably suffer from some form of neglect. As it is this man, quite reasonably I believe, decided that nothing was being done for him at the hospital and took his own discharge. Having nowhere to go and with severely impaired mobility, he ended up abandoned near the main road around the hospital. Apparently he’d lay there for about a month before he first came to my attention. It was a Friday night and I was heading out for a drink when I saw this man with horrible looking dressings around both his feet, full of mud and completely tattered leaving the inside partly exposed. His wounds were so bad his leg bones were actually visible. That is bad news in any orthopaedic book I know! Thus I decided to get him into hospital and work him up for a debridement at least until we can stabilise him for bilateral above knee amputations, which is the only thing that could save his life. That’s when the whole can of worms opened up. Firstly there was no one willing to carry him 100 yards to the hospital on the streets, because let’s face it, no one wants to assist a mad man like that here! I eventually paid some guys to take him in. Once in the hospital more obstacles would crop up. The admitting clinician for one did not feel like handling him alone and in the end I had to assist her with the initial clean up and change of dressing until 8pm. That was a gut-tester in its own rights and revealed an important fact to me- that maggots residing in his bandages had potentially saved his life! I don’t know how beneficial the other bugs in there would have been though. Having somewhat cleaned him, I starved him for the next day thinking someone would echo my thoughts that this guy needs an operation urgently. To my surprise that was far from being the case. Having decided to come in on a Saturday just for that, I had to first face up to a spate of pathetic mockery, where this naive muzungu had believed he could save this man’s life who deserved to die just because he’s mad and does not have a guardian!! When I refused to laugh, it became clear I wanted an anaesthetist to work this man up (He was not a diabetic and had normal bloods- hence confirming that the state his legs were in was in large part due to neglect). Further neglect would claim his life and I was not prepared to allow for that. Thereafter it was a whole barrage of excuses that simply got laid in front of me so we can’t go ahead with the operation. Ranging from medico-legal concerns about consent through social issues about his post-op care (which I had thought about and addressed by planning to refer him to our mental hospital post op and then organising a wheelchair for him) to the non-availability of suxamethionium in our anaesthetic department (it’s like having no blades in a surgical department or no plaster in the orthopaedic department- which, sadly, is also known to happen up here!), the reasons kept piling up. In truth, the main reason was that no one was interested in this mad man (me or the patient?!). So, having concluded that it might be weeks if not months before anyone decides to assist me with this patient, who will inevitably conclude once more that there is no point in him staying in hospital, I referred him to Blantyre for some more specialised people to handle his care. It turns out then that just on the day that the defaulting anaesthetist from Ntcheu rethought his position on this case and congratulated me for rescuing the poor man before the rainy season (which would have wiped him out like a fly), I visited the ward he ended up in Blantyre... only to find that the resistance to assist a guardian-less psychiatric patient was no different there than it is in Ntcheu. The legs were back to almost their original state of decay with little care being administered to him and the plan was just to send him back to Ntcheu without the amputations. For what may I ask if not to die a peaceful death?! I’m afraid not while I’m there.

Amputations
Speaking of amputations, I’ve also dealt with a small series here which have very much enlightened my practice. We’re talking of low-resource settings here and everything you do has to be adapted to this. So when you do your bone cut in a below knee amputation, you have to make sure you have enough Giggli wires to get you through it all. Because if you don’t, for example because the wires have snapped (common problem), then you don’t have an electric saw to finish it off. And this is what happened in my first case. The bone was rock solid and my only tool left after my 3 Giggli wires succumbed to heat exhaustion was a blunt osteotome! So I ended up doing a closure under tension and hoped for the best. Close monitoring allowed me to anticipate a breakdown of his wound, and I took him for a revision before that happened. Thankfully the case was salvaged. So on my next case, I had extra wires and very sharp osteotomes on board and proceeded without much difficulty. Then I also learned that by holding the wires straighter (with upward pull) rather than in an acute curve around the bone, the heat generated was less and the wires didn’t break. Having an assistant pouring cold water slowly on it also helped. As for the osteotomes, they helped in dealing with the fibula issue, which I always used to cut in one stage proximally, with the inherent danger of disturbing the neurovascular bundle in that fairly blind method. What of course turned out to be better was to do a safer osteotomy distally, take the leg off (sorry for that graphic wording but that is exactly what it is!) and then shorten the fibula in a second stage. It’s a bit unfortunate that I’m refining my practice in this way, since any hope of supervision in a district setting is unrealistic. Some people would argue that these patients should be left alone instead, but the outcome of that would be near-certain death from spreading sepsis as the central hospitals could not cope with such referrals if all districts were to send every amputation to them. In most cases also they are straightforward and uncomplicated and the recent series only illustrates some difficulties that sometimes arise. Just in the same way as most Caesarian sections are dead easy, until the massively bleeding one comes along and everybody then gets agitated and starts asking why we’re not sending them all to a central hospital to be dealt with. The answer is that, in practice, and with our resources, this is simply not possible and some complications have to be accepted to be able to continue to provide for the wider majority of cases that go without (this is called the theory of innocent shields of threat in philosophical bioethics parlance).
I did one final amputation in that time which will add to my bad series and again I don’t think this reflects on the general quality of amputations at the district setting. It does however highlight one management misjudgement of mine, which was not to be aggressive enough from the start. My patient was a forty year old diabetic man with a gangrenous septic little toe. His leg however was more severely infected as evidence by his Xrays which showed osteomyelitic changes as proximal as his midfoot. For some reason (partly mixed with influence from other clinicians), I opted for a ray amputation and loads of antibiotics to try and save his leg. That proved to be the wrong choice as he immediately developed a wound infection. I then thought that I wouldn’t wait any time and bring the amputation level proximal and do a Syme’s for him. That again was not proximal enough and unfortunately, he ended up developing gas gangrene (classic soft tissue crepitations). This time, I put my gloves down and decided to refer him straight away to the central hospital for a higher level amputation and better diabetic control (since all we had left was out of date Glibenclamide). I found out later he had an above knee amputation, which was healing well. Strangely, some 10 days post op, he went into a diabetic coma and succumbed to that. I can’t help wondering whether that could have been helped by an earlier referral.

The rest of my surgical work has been a mix of skin grafting, soft tissue work and even an open reduction internal fixation. The skin graft was for a long standing burn wound which was not healing with simple wound care on the ward and which I was referred late. I did a combination of split skin and morsellised skin grafts (similar to pinch grafting in principle but with the donor site further from the wound, where an elliptical full-thickness skin is excised, defatted and chopped in morsels which are then just laid on the recipient site). The main advantage is the donor site which heals much quicker than the split skin (which also with poor equipment can end up much thicker than intended). The soft tissue case was a polysyndactily of the 5th toe, where the importance of careful surgical planning was demonstrated at its best. I was lucky to do this with my clinical officer colleague who could hopefully retain this as a learning point. We identified the dominant toe and all its components that needed excising from a pre-op Xray, which I insisted on having in theatre (often it’s left on the ward). The incision was a S-shaped flap which closed beautifully. The final case, the ORIF, was a tension band wiring for a shattered patella. With no Xrays and a single K-wire which had to be cut and used twice, we ended up cutting through one side of the patella- but by protecting the leg in a backslab post op, and advising protected weight bearing, we managed to maintain the reduction and restore his extensor mechanism.

I feel that I may not be operating as much as I would initially have liked to in Ntcheu. However, with the extent of ward clinical as well as organisational work I am involved in, which arguably is much more important that operating in a district setting, I am quite happy with the extent of this surgical work and its coverage. Every new case provides a learning opportunity to me in this unsupervised setting and by applying my own safety criteria stringently to each case on its own merits, I have the reassurance that I am not going beyond my capabilities.