Tuesday, June 23, 2015

The 4 M's

These days we've seen a lot of trauma at the hospital. As a young surgeon, trauma seems really exciting.  As you get older, it just seems annoying.  It is so stupid, so avoidable, but it takes so much effort to treat. In the setting of trauma, I have four enemies. 

The first is the motorcycle. There is a Chinese-made motorcycle called the "Senkhe" (or some variant). A Senkhe can be purchased for about 500$. They drive these motorcycles like madmen. Scarcely a day goes by when I don't see several two or three Senkhe victims. Mastaki is a 15 year old who was on a motorcycle with two buddies. He has a skull fracture with a major leak of cerebrospinal fluid from his nose. He has a fracture of the humerus, which required a plate and screws, and a fracture of the radius which we treated with a cast. He has now awakened from a coma, but I suspect he has a major contusion of the frontal lobe of his brain. He knows who he is, and where he is, but he has a serious brain injury. He sounds pretty bad off, until you learn that both of his friends on the motorcycle died. I could tell you many stories of patients who have horrible orthopedic injuries. As a motorcycle rider, these injuries do give me cause to ponder.  I have a Honda, however, so I should be ok. 

The second enemy is (predictably) the machine gun. The fact of the matter is that Eastern Congo is a violent place, and my old friend the AK-47 is alive and well. In the area east of here there has been fighting between the Congolese army, the UN "Peacekeepers" and a rebel group known as the FRPI. This is, of course, the Force for Patriotic Resistance in Ituri.  This conflict has been heating up as of late, and we've received some horrible injuries. One man had his jaw shattered. Several young combatants were shot through various limbs. Beside the conflict victims, we have the civilians who are injured by bandits, or from stray bullets. I have a 10 year old girl and a 60 year old women who were shot. In this business, one learns to hate guns. Still, in this line of work, they do offer some job security.  

The third is the gold mine. As it turns out, there is a lot of gold in this area. I wish there was no gold here. The lure of easy money drives families apart and results in a lot of vices. It also entices able-bodies young men to dig down and tunnel, like rats into the depths of the earth. These tunnels cave in, killing many and resulting in terrible injuries. At the present time we have five patients who are paralyzed, and two who have severe pelvic fractures. One man had a stone fall on him, rupturing his urinary bladder. On a good day, these miners will show up at the local store to buy beer and cigarettes. They weigh out the gold on little scales. A matchstick's weight of gold is worth about three dollars. Some people are making a killing on gold. Not these guys. They're just getting killed. 

The fourth enemy, particularly in this season, is the mango. So far I've only seen a couple of kids with broken bones. This is because the season is in full swing and the mangoes are dropping like manna from heaven. It gets dangerous later on the season as those ripe mangoes are high up in the tree. Mango trees are notoriously weak. Some days it seems like there are as many kids dropping out of the trees as mangoes. Every year I see a few that die. I like a good mango as much as the next guy, but I haven't yet tasted one I was willing to die for. 

Today I had a good one. I suppose it fits under the "motorcycle" category, but perhaps I could make an additional category called "moo". It is a guy in his 30's, who seems intelligent enough. He got up early in the morning and headed out on his Senkhe. Either his headlight was not working, or it malfunctioned, and he found himself in a large herd of cattle which was on the road. He managed to crash into a large cow and basically impaled himself on its horn. Now that I write this, it seems implausible, but that was his story. The horn entered his chest, barely missing his heart. He presented with what we call an "open pneumothorax" or, more colorfully, a "sucking chest wound."  This is a hole in the chest wall. If it is large enough, the air will preferentially go through the chest wall, rather than through the airway. I found him breathing with some difficulty. Nobody seemed to know what to do.  Lesson of the day: if there is a hole in the chest wall, try to seal it with something. The general dictum is that you put a piece of plastic over the hole and tape it on three sides. That permits air to leave the chest cavity, but not to enter it. When we got him a bit stabilized, we brought him to the OR. He had a gaping hole, through which the heart and right lung were visible. The horn had passed to the side of his heart, but had torn through the internal mammary artery, which runs down the inside of the chest well. After we ligated the bleeding artery, fixed the hole and gave him some blood, he felt much better. I've replayed the scene in my mind a couple of times, and it still seems bizarre.  Is it really possible to drive a motorcycle with no headlight and impale yourself on the horn of a cow?  It seems that it is. 

So, those are my major challenges: motorcycles, machine guns, mines and mangoes. My real challenge is to share the love of God to people who are suffering here.  Many of them, one must concede, are suffering because of stupid things.  I continue to work closely with the trainees that pass under my tutelage. Teaching Congolese doctors is the only way I can hope to have a greater impact on healthcare in this area. It is challenging, infuriating, frustrating, maddening, but never boring. 

Two days ago we had another motorcycle incident. There were three big guys on a Senkhe. This blows my mind.  The story is stil hazy, but the crashed into a bus (or vise versa). One had an open fracture of the tibia and severed his patellar tendon. One had a femur fracture, which we treated by placement of a steel rod with interlocking screws. The last had a dislocated hip and a fractured pelvis.

It's time for us to get out of Nyankunde for a bit. We've been here for six months without a break and it's time for a change of scenery. We are going to take a little road trip to Uganda. We'll see some animals, eat at a restaurant, do a little shopping. Most importantly, we will be spared from patient care for a bit. We love our job, really we do, but it takes a toll and sometimes we just need to get away!

Warren

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