When We Come To It

Morning brings Mount Kilimanjaro out from behind the clouds!  The view of the mountain always makes me feel more energetic for the start of the day.

Mrs Tree and the boys are to journey to an orphanage today.  Hopefully she will post her adventures sometime soon.

My day begins again with morning report.      The first patient is very complicated.  She was admitted to the orthopedic team with sepsis, pressure sores, leg weakness, history of Tb, history of “autoimmune” disorder, malignant bone disease,  3 months postop a hip fracture, and now is nonambulatory.  I won’t try to turn this blog into a patient presentation, but her case occupied a large chunk of morning report.  Where is her infection?  What is her source?  What about this malignant bone disease?  Tb?? What is auto immune – not HIV, but rheumatologic?  The new intern was understandably a bit overwhelmed by this patient who has problems across the breadth of medicine – and the orthopedic team was in charge.  In the States, this patient would rapidly have more consults than fingers.  However, here, consultation is very rare.  I am not sure if it is a point of pride, accessibility, cooperation issues, or perhaps a bit of all.  It became apparent that she could not be solved with third person discussion and we agreed to resume talks at ward rounds.

As morning report concluded, I started to head to ward rounds, but was grabbed by a chief resident and asked to come to the OR.  They were in need of hands.  I found the intern and gave her a few points to look for on rounds with the above patient.  She felt there would be an upper level resident to assist, and I left the ward behind.

Off to the OR – 

There are four cases for today

1-Open pelvis fracture with large perianal wound and open femur.  Ortho has been washing out, but general surgery has looked at the wound.  Now she may need a colostomy.  Her case has been delayed due to low Hgb and blood availability.  Plan – repeat debridement and irrigation.

2-Open knee injury 10 days old.  S/p 1 washout, needs revision washout and debridement

3-Closed distal 1/3 femur fracture in 87 yo patient.  Over 3 weeks out.  Poor preop imaging. I met her on rounds yesterday and the skeletal traction was clearly not holding her out to length.  Yikes.

4-Closed distal medial condyle femur fracture in 67 yo patient.  X-ray is 1 AP of the knee.

The senior resident will do the washouts and I have been asked to help on cases 3 & 4 in the other room with two junior level residents (actually called registrars meaning they have completed intern year but “choose” to do extra years before starting residency.  I am unclear exactly how this process works.)

We begin the distal femur.  Xrays are sub-optimal but suggest a fairly straightforward oblique fracture of the distal 1/3 shaft of the femur.  The plan is a retrograde femoral nail – without fluoroscopy.

We begin.  The patient has had a shortened, displaced fracture for 3 weeks and callus is beginning.  We work meticulously to try and free the bone edges from the scar and callus while preserving soft tissue as able.  This fracture bears us gifts – significantly comminuted that was unappreciated on the xrays.  A fresh injury would have allowed us to preserve more soft tissue attachment and achieve alignment easily for nailing,  but the age of the fracture forces us to release tissues more aggressively.  Unfortunately, this leads to further fragmentation and poor soft tissue support.  We press forward with nailing, but the nail instrumentation available lacks enough distal locking options preventing adequate fixation.  It becomes clear that we must abandon the nail and move on to a plate.  As described before, finding appropriate plates and screws is a process, but we are gradually able to secure a lateral plate to the femur in a bridge plate mode.  The bone is remarkably poor quality and the comminution spans over 6-7 centimeters of the distal femur.  Alignment is achieved, plating seems secure, bone fragmentation and need for grafting is daunting.

In conclusion, I am satisfied with our surgical performance but dissatisfied with the circumstances up to surgery.  We review this ad nausea in the OR and I hope to address it again with the other residents in the morning.  The goal is not to point a finger, but understand how we can more efficiently, safely, and adequately have treated this fracture.

The second femur case must be canceled because we have opened all the femoral plating trays on the first case.  Such is life in the trauma OR.

I move to the other room to check on the open knee.  This injury is terrible.  The patella and patella tendon are gone.  The knee joint is exposed and the soft tissue injury surrounding it is devastating.  We discuss adequate debridement, spanning external fixation, and if there are reconstructive soft tissue services (ie. plastics) available.  Apparently, general surgery does some flap coverage.  Hopefully they will be able to evaluate the wound.

I journey home with the now familiar feeling of victory and defeat.  I am teaching and sharing knowledge.  However, the enormity of the need is overwhelming.  As I write this blog, I reflect back on the patients I have mentioned here previously.  How are they doing?  The compartment syndrome, the spinal infections, and beyond.  I, myself, have learned so much about medicine, improvisation, and scarcity of resources but I still am not able to perform a simple task of locating these folks to check on them.  It is easy to assume from beyond the hospital halls how changes/improvements can be made.  It is easy – from the outside – to point,  critique, and correct.  But as I experience and breathe it, I applaud the men and women here for their efforts and unflappable smiles.  Do not judge these events harshly, and changes, as they come, will be more like evolution than revolution.  We are back to drops in the ocean.  Drip drip drip drip drip.