Clinical Digest 12

Back after a long absence. This has paradoxically been the most exciting period of clinical activity in Malawi. Moving from low rumbling Ntcheu to the epicentre of trauma in Blantyre, while joining the on-call registrar rota, has come with a predictable surge in medical/surgical drama. Not a single week goes by in Queen’s when I don’t think, “well I could make a ‘case report’ out of that”! The somewhat perverse sense of medical excitement(perverse because it directly means that someone’s tragedy contributes to the doctor’s direct pleasure- although I have got over that one, through my “survival in a fast and stressful environment” doctrine) is satisfyingly tempered by the widely diverse range of my duties here: weekly teaching of 3rd year medical students and trainee ortho clinical officers, examining, course facilitation, clinics, drafting of a reference manual, outreach clinics to Ntcheu and Thyolo and other more epidemiological interests in these 2 locations. To say that I’ve got my work cut out for a year is quite an understatement!

The two ER-style dramas that have formed the highlight so far of my 2months in Queen’s have both been a direct consequence of the surprisingly intense second wave of the rainy season, while I’ve been on call. The soubriquet of trauma-magnet has indeed followed me to this corner of the world! The proof is that my 3rd on call was the quietest I’ve ever had. Hold on, that can’t be! That on call happened to be one I had effectively swapped and the “swappee” turned out to be a scene from a horror movie scene- assaults, lacerations and open fractures needing theatre attention for all night.

Land-slide wall
So here I am, slightly nervous that this is going to be my first proper call in more than a year and having not yet worked the system out fully. I pre-empt disaster by doing a systematic round of all relevant clinical areas to pick up the cases that might be referred to me during the night. Satisfied to have cleared all that up before 11pm, I yawn a final goodbye to my orthopaedic ward sister, who tells me “Hang on. Don’t go far!”. As anyone who has ever done a medical call knows, that statement is usually paraphrased as “Don’t even think of going anywhere cosy tonight!”. Just outside town, a multiple casualty has occurred, where a number of people who were standing by a wall suddenly had its whole weight collapsing on them! 2 ladies were severely injured, one of them pregnant. I find the non-pregnant one collapsed on the surgical ward without a pulse, being attended to by the intern on call. No bleeding visible anywhere, but a ghostly appearance. Pallor is a clinical sign that is certainly easily detectable on black skin, despite certain doubts I’ve heard to that effect. One feel of her pelvis and you got the diagnosis: Fractured Pelvis. But before that, the bit which is the real challenge here, is the ATLS resuscitation protocol- your ABCDEs. A challenge since ATLS was written with your western high adrenaline tertiary trauma unit in mind, not an under-resourced African hospital, where more than half of your assistants have never even heard of ATLS! As it was, my patient’s blood pressure was in her boots, with no accessible peripheral veins in her arms. Thus, aptly I decide to go for the area around her boots indeed and do my first unsupervised saphenous cut down. As much as is feasibly possible, I secure it and manage to administer just the amount of fluid and blood required to revive her. But as soon as she gets back to the ward (she was taken to theatre recovery for that), some “clever-clogs” decides to hang her fluid bag from the same drip stand as is normally used for the arm line. To no-one’s surprise, the line is too short and ends up simply yanking my cannula out!!! By that time, she has a recordable blood pressure though and gets an arm line inserted. The rest is standard open book pelvic fracture management- sling around the waist and legs, maintain BP (stable, therefore no need for ExFix in the middle of the night [which would incidentally have been my first one too!]) and wait for the morning to plan her definite fixation.

The pregnant lady, given the mechanism, also ended up with a pelvic fracture. However her clinical picture was entirely different, with pain being her main complaint. Everything else was stable and the reason for this stunning difference lay in the Xray pictures- whereas the first one was probably facing the wall as it fell on her and had her pelvis effectively opened up from the symphysis, the second one must have either been hit by the side or had the weight of the wall somewhat dampened by something else, sustaining a bilateral pubic ramus fracture instead without any posterior element, hence maintaining the integrity of that polo mint structure overall. That budding fetus in there must be relieved things didn’t happen the other way round!

About mini-buses
Remember that flash storm I once experienced at the start of my placement? Well I do remember thinking to myself that day “I’m glad this isn’t in the middle of the night and that the road is clear”. Such was not the luck of the casualties I admitted on that second ever call in Queen’s, when I was advised not to go far! A minibus effectively got sandwiched between a hauler truck behind and a car in front in what I remember to be the biggest downpour of the season. Impossible to attribute the blame to any party in particular here, but in spite of the commonness of reckless driving in this place, I think even the most meticulous driver could have found this unavoidable that night. The only safe option would have been not to go out. Those who made it alive (not sure how many but there were deaths on the scene), were barely hanging on. With full ATLS awareness in mind, the team on call (2 registrars, 2 interns and 2 nurses), used a multiple casualty approach, treating the most severe injury first, then the others. We split in 2 teams and managed to stabilise the 2 most unstable patients, both with clinically unstable pelvis fractures. Before I could even measure the vitals on my patient, the other team’s patient was already being wheeled to theatre, where I eventually joined them. I was effectively the senior orthopod for that night, since my consultant’s phone went unanswered on at least 10 occasions. The patient ended up needing multiple debridements, elevation of a depressed skull fracture (by the general surgeons thankfully) and an arm amputation. She then went to ICU intubated. It would have been a miracle if she survived and she didn’t. The second one also had multiple serious wounds that needed debriding, including open fractures of her forearm. Her outcome was more positive. As I got to the 3rd patient, whose main injury was a closed tibial fracture, the latter had evolved into a nice ballooning compartment syndrome. Now the dilemma arose about how I was going to do this case for the first time ever unsupervised. I’ve read a lot about it but this is a condition I’ve always tried to get involved in but never saw one while being on duty. So, assisted by the general surgical consultant, himself somewhat rusty on his orthopaedics, upper GI being his thing, I went on to translate book to limb for the first time. In that medically perverse fashion, I will admit to you that the opening up of a fascia which is in compartment syndrome must be one of the most satisfying feelings in surgery that I know of! It just bulges out and you can see the pressure offloading at once. And it’s a limb saved, potentially a life! Next big question then arose: do I fix him in the middle of the night, as indicated by the grade of his injury (Gustilo I) or do I plaster his leg with these massive open wounds? So I decide to go for the ExFix option and taught myself how to use this new kit that I’ve never used in the process. As it all held together straight when I tightened the final screw, I heaved one sigh of relief only surgeons can understand the meaning of! The last patient wasn’t mine and had mostly maxillofacial injuries, with a minor head injury. An on-call spent almost entirely in theatre and indeed a highly rewarding one. The way I downed that Coke I managed to lay my hands on at the end of that shift would be a serious contender for the next Coke advert without a doubt!

The rest
I wish I had enough space and time to document the rest in its full scope here. But since I have to actually DO the rest, I won’t spend much time DESCRIBING it. In brief it’s a mixture of trauma and elective work that I’ve not encountered much before. The trauma work is incredibly fascinating, with a lot of them presenting late and being non- or mal-unions. The tools we’re using are ones that are not so common in the UK anymore, e.g. K-nails and even then, improvisation is the key. Like just last week, we needed a 10x38mm nail and had nothing near it. So we combined two 8x42mm and then spent half an hour trimming it to 38mm! The elective work, for its part, is simply out of this world. Spinal surgery with the Prof- TB decompressions, laminectomies, fusions, pedicle screw stabilisations. A whole repertoire of terms that were hitherto very unfamiliar to my work vocabulary, let alone the spectrum of diagnoses involved- neurofibroma of the cord, syringomyelia, monofocal fibrodysplasia and even the first case of post op malignant hyperthermia I’ve ever seen.

This is the cutting edge of orthopaedics in the third world I think and I’m really thrilled to be involved in it. The learning curve is phenomenal but the sense of fulfilment even more so...