Clinical Digest14

Gunshots

It has been another extraordinary period on the clinical front at Queen’s since the last update. On the one hand, there’ve been hair-raising moments like the recent unrest on the streets of Blantyre (remember 20July). On the other hand, there’s been a recent overnight escalation in my level of responsibility at the hospital. Both my orthopaedic consultants have been on leave simultaneously, leaving me to coordinate the entire orthopaedic department, with the assistance of a visiting surgeon from Holland, Jan Paul Frolke and Christopher (the chief OCO). Being the one making all executive decisions in the department I have to say is not something I’ve been called up to the task for before. Yet the challenge of it all generated enough motivation and energy required for this new role. I managed to reshuffle my duties to include more ward rounds, while making sure theatre lists kept running as normal. This felt like self defence from predators at times, with everyone around seeming to have their sights on this potentially vacant slot, desperately poised to make a go at it anytime. Thus more than once I had to fend off these predators and claim my territory!

How fateful that the majorest alert that I will have experienced in Malawi had to occur precisely during that period: The anti-government protests on the 20th of July!! I actually considered myself really lucky on that very day not to be on call, thinking I would plan the trauma list the next day to deal with the repercussions. It was a grave assumption to make that things would revert to normal by then. Instead of picking up the pieces from the day before (a total of 1 patient, who ended up under plastics instead of orthopaedics), I amassed a total of 3 severe gunshot injuries freshly from the aftershocks that were still happening in pockets of Blantyre the next day. It was a formidable experience to be on the frontline operating on these cases till early hours of the morning. Closest thing to MSF ever happened to me. LIVE gunshots! I remind one here of this strange phenomenon of the bizarre medical arousal which is a natural pill against losing it all in the heat of extreme moments in the medical/surgical profession.

The first case got sorted with the help of Dr Frolke who was still in the hospital at the time- an open elbow fracture with massive soft tissue destruction, including the ulnar nerve. We fixed it primarily with a tension band wiring technique and prayed for our plastic surgeon to work his magic on providing soft tissue cover subsequently.

The second case was a shattered wrist, with a through and through wound, in which the bullet somehow managed to skirt the median nerve and most tendons. The ulnar was not so lucky once again, but the damage done was surprising little considering the bullet that caused this injury. The wrist only needed a major debridement, after which it had enough soft tissue cover to hopefully deal by secondary intention. Of course, the possibility of any reconstruction of the joint itself could not be entertained for this patient within the resource setting of Malawi, but luckily most of the damage to the bone did not involve the joint.

The final case was what kept me on my toes till autopilot had to kick in. I kind of inherited this patient from the surgeons with a diagnosis of a comminuted open fracture of the proximal humerus. Since the wound was all dressed up in a bulky bandage to control the haemorrhage, I elected to do my examination in theatre. That is when I discovered the one tiny bit of information that was left out in the referral: that the entry wound of the bullet was actually through the chest while it was the exit wound that lay around shoulder! Partly owing to the delays encountered in getting operations done out of hours in Queen’s (some kind of a systematic deterrent to operate on anything but the most serious of all cases after 5pm),the patient had also managed to lose a significant amount of blood by the time he appeared on the operating table. Here I was expanding my initial plan for this patient to include a chest drain insertion, fluid and blood resuscitation in addition to the shoulder wound debridement. The latter was a typical example of the bag of bones description we reserve for the most severely comminuted fractures in the orthopaedic world. Unfortunately for the victim, his ‘bag’ was also in tatters and he would be another case on our esteemed plastic surgeon’s list for the next week.

That was a day in the life as Ortho reg in Queen’s. The remaining days found me mostly operating on forearm and ankle fractures, both fresh and non/mal-unions. The coincidence of finding so many similar pathologies in that short time provided the perfect opportunity for me to develop my surgical technique to the point where I feel quite confident to tackle these independently now (which I ended up doing twice). I owe a lot this to the very clever supervision from our visiting surgeon, Jan Paul Frolke and Christopher as well as to the encouragement from another visiting surgeon from across the road at Beit CURE orthopaedic hospital. It is incredible how much one can achieve from just having the right combination of factors in place at the right time. Some of these factors, which a priori might appear to be obstacles, indeed prove to be the catalysts in the learning process. Maybe that’s a lesson in Orthopaedics that resonates with my mountaineering vibes... There’s no such thing as bad weather; only inappropriate clothing!