Complications

>
> "I've got another patient for you, this time it's really serious."
> Lorraine's voice on the other end of the line sounded panicky. "The
> daughter of one of our pastor's has been hit by a car and her leg's
> broken and there's blood everywhere!"
>
> "Ok, well send her to the hospital." I reply.
>
> "Right. We're at the cellphone tower. They've taken her to a
> traditional bone setter, but I've convinced them they need to come
> to the hospital. We'll be right over."
>
> "Alright. Just tell the nurse or the gatekeeper to come get me when
> you arrive. I'm at home."
>
> So much for a leisurely Saturday. I'd spent the morning telling the
> story of Joseph to a group of teenagers and using it as an example
> of responsible sexuality and speaking to a group of adult Christians
> later about the positive sides of Islam. Then a brisk ride to the
> river to try and cool off. I always forget how just when you think
> it's gotten really hot and unbearable it can just get worse.
>
> I send a text message to Samedi, Simeon and Abel and slowly put my
> scrubs on. As I look out my front porch, I see a truck pull up to
> the hospital. The patient must have arrived. I saunter over and
> see a crowd behind a Toyota Forerunner. Inside is a large, moaning
> woman with tightly coiled braided hair, new clothes and a blood
> soaked wrap around her twisted, swollen left leg.
>
> With many hands making light work she is quickly transferred to a
> gurney and wheeled into the OR. She has an obvious femur fracture
> with a tiny wound telling me the bone had poked out at one point.
> She has a similar wound over her tibia just below her knee but her
> lower leg seems stable. There is also an open fracture of her big
> toe which has been reduced. Her left thigh is twice the size of her
> right one and she's obviously lost a lot of blood already. Her
> heart rate is 150-160 but her blood pressure is holding. We start
> two large bore IVs to try and replace her lost blood volume as
> someone calls the lab tech on duty to test the family and friends
> for possible blood donors. Her heart rate quickly drops to 110-120
> with a couple liters of IV fluid.
>
> After Simeon injects the antibiotics, I give her some Diazepam and
> Ketamine to dull the pain and allow me to place a tourniquet around
> her upper thigh to slow down the blood loss. We quickly wheel her
> into the inner OR, give her a spinal anesthetic and prep and drape
> the leg. WIth the blood supply cut off to the leg by the tourniquet
> I know I only have a limited amount of time to get this operation
> done. I figure it shouldn't be as hard as the many other fractures
> I've operated on recently because this one is fresh. All the
> other's have been old ones with poorly healed bones needing to be
> cut apart, wound contractures, scar tissue, infections and many
> other complications. I should know better than to think something
> will be easy.
>
> After praying, I slice open her thigh over the puncture wound.
> Swollen muscle pops out under pressure. I cut down do the fracture
> and find nothing but shards of crushed bone for about 10-15 cm in
> the middle of her femur. A pre-op x-ray would've been nice, if we
> had a working x-ray machine. Now I have to go by feel as I probe
> the wound with my double gloved finger. I decide to go through the
> knee to insert the rod since she has had so much blood loss and this
> allows me to keep the tourniquet on. As I expose the entry site,
> dark blood spurts out of the knee joint confirming my suspicion that
> she also has a fracture of her upper tibia plateau into her
> articulation.
>
> Using the SIGN technique I just learned in August, I bore into the
> bone and insert the first reamer to clear out the bone marrow in
> preparation for the metal rod I'll use to fix the fracture. Going
> through the distal part of the femur is no problem. But since the
> proximal part is shattered I have a difficult time finding the
> hole. I try and explore with my finger through the other incision
> to guide the reamer but finally realize that bone fragments have
> gotten jambed up the marrow cavity blocking the entry of the reamer
> (and later the nail I want to insert). I have to put it in from
> above. I expose the hip, swab it with Betadine and cut down to the
> bone. The patient is quite large and muscular and the hole is
> deep. I pray desperately as I've already wasted a lot of time and I
> don't have much left on the tourniquet before I have to let her
> start bleeding again. Fortunately, there are two bags of blood up
> and running now.
>
> I insert the awl and find the marrow cavity. "Al hamdullilah" I
> shout as I start the progressive hand reaming. I finally hit the
> largest size that will easily pass and call for the right sized
> rod. I carefully attach the external guide apparatus and twist and
> hammer the rod into the bone. With Youlou pulling on the leg from
> below and Samedi twisting and positioning over the fracture site we
> are able to get the rod into the distal section and stabilize the
> injury. I position the guide pin, incise the skin, place the drill
> guide, drill the first cortex of bone, insert the hand hole enlarger
> and twist in but don't feel it enter the hole of the rod like it
> should. It means I'm a little off. I use the curved hole finder to
> reposition the apparatus and then am able to locate the whole again
> with the next drill guide so I can drill the second cortex. I
> measure the length from cortex to cortex through the drill holes and
> place the first fixation screw. The second one is easier and the
> two proximal ones even easier.
>