Noticeably Absent

erin pichiotino
Erin Pichiotino, M.D. ’17, M.P.H.

Orthopedic Trauma rounds are every Monday morning. We visit each and every patient, take down dressings to look at wounds, review x-rays, and as a team come up with a plan for the week. Other than that, the orthopedic officers and nurses are responsible for following the plan, performing wound care, administering antibiotics and otherwise managing the patient, consulting the surgeons if and when necessary for proper patient care. The day-to-day needs of the patient including procuring implants and medications, bathing, feeding, and physical therapy if needed are taken care of by the caretaker, friends and family members who come to the hospital to help. Most of these caretakers sleep outside the hospital on the concrete, washing and cooking in the open space between wards.

Last Friday, as we waited for the theater to start, we did an impromptu ward rounds. What we found was many of our patients with infected wounds. We were told there were no gloves, so the officers weren’t taking down dressings. Carl and I started handing out gloves (sterile and non-sterile) that we had in our pockets and slowly we were able to make our way through the patients. What stopped us in our tracks was a man with an external fixator from an open tibia fracture after a boda-boda (motorcycle) accident.

Something we take for granted in the U.S. is our sense of smell. We hear about nurses on the wards being able to smell Clostridium difficile and pseudomonas infections. Here in Uganda this skill is a necessity. The smell was the first indication that something was wrong. Then, we noticed the flies. The wounds were weeping a greenish fluid and there were patches of flies all over the bandages. As I observed, I noticed a weird spasm or tremor in his leg. We asked him questions and he was unable to answer. I asked the resident if the patient was in septic shock. He asked me why I thought that and I responded, “fever, tachycardia, hypotension, altered mental status.” The resident told me to ask the patient again to speak. When I did, I realized he was unable to open his mouth. He had lockjaw. He had tetanus.

After a traumatic injury in the U.S., every patient is given a prophylactic tetanus shot. Here in Uganda, there are so many accidents and so few resources that this doesn’t happen.

Did we give him tetanus with the insertion of the external fixator? I wondered. When was the last time someone checked on the patient or took down the bandages to check the wound?

Perhaps it was inevitable that the patient acquire tetanus, but we didn’t have the resources to treat it either way. The protocol is for antitoxin, antibiotics, vaccination, sedatives and supportive therapies. We weren’t equipped on the orthopedic ward to provide this. The team discussed the best approach and consulted the medicine team to see if we could transfer the patient for a higher level of care. Medicine denied the transfer due to the open and contaminated wound and external fixator – it wasn’t safe for the other patients on the ward, they said.

On ward rounds this Monday, the patient was noticeably absent. I was hopeful that he had been successfully transferred to the medicine ward for tetanus treatment. When I inquired, I was told they took the patient to the operating theater early Saturday morning to amputate the infected wound. He died several hours later.

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