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- Apr 17, 2005
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Currently I am doing a clerkship in Ethiopia. The pathology here is simply indescribable. I have seen things I am certain I will never see in the west. People here simply have no access to medical care and cannot afford the medications that are needed to treat whatever ails them. Many live on less than $1 per day, and some I have seen on 10-20 cents. Yeah, I know, sounds unbelievable.
This week I went to a wound care clinic where we saw some of the poorest people in Addis. Their conditions were primarily chronic and untreated festering purulent wounds. Osteomyelitis with auto amputation, visible bone from chronic ulcers, maggots in wounds, cellulitis, chronic ulcers, etc. In one case I saw a man that had the entire top of his scalp eaten away as a result of an injury some time back. I am not sure if it is a malignant transformation (marjolins ulcer), Leshmanaisis, or a chronic oseomyelitis. Either way it was purulent, oozing pus onto his shoulders and back, and painful. We put viscous lidocaine on it (Which did little), cleaned it, and I went to a pharmacy and bought him some cloxacillin. Perhaps it will do something to help but we had no ability to perform pathology or culture. It probably helped me more than him.
One of the problems we faced was cleaning some of these wounds. It was extraordinarily painful in the majority of cases. We have the availability of lidocaine and other anesthetics, donated by medical students from elsewhere, but in many cases the wounds were so infected and large that anesthetizing them was impossible. In other cases I have seen, I was reluctant to insert needles thru cellulitic tissue for debridement. So, I thought I would ask for some input from some of the more seasoned EPs out there. What is a reasonable area to anesthetize with simple infiltration? What is your philosophy on injecting infected wounds or thru cellulitic tissue. What about the wound margins? Some are keen on cutting away dead tissue from infected wounds with a scalpel, I have been more conservative.
I am aware that the anesthesia is less effective in acidic environments and I do not want to create wound tracts in infected tissue, especially where the infected area lies close to a bone. I would hate to create an ostemyelitis from cellulitis. I have looked into nerve blocks, and for some of the distal extremities, they are pretty straight forward. For the forearm or leg, or proximal extremities, they pose much more of a problem. I would like the ability to anesthetize the distal leg and forearm, but I am reluctant to perform brachial plexus blocks. What might be a minor complication in the US would mean death here. Of course, I have been told by Ethiopian physicians that they do not use local anesthesia or sedation at all, even during sutures or large areas of debridement. They do not generally have it available and do not view it as the standard of care. In fact, some Ethiopian students laughed at the suggestion of it. These were great students, but they have had no exposure to pain control.
So, any ideas or suggestions? Perhaps I'll just do what everyone has been doing, the best they can. For now my philosophy is "Primum Non Nocere."
This week I went to a wound care clinic where we saw some of the poorest people in Addis. Their conditions were primarily chronic and untreated festering purulent wounds. Osteomyelitis with auto amputation, visible bone from chronic ulcers, maggots in wounds, cellulitis, chronic ulcers, etc. In one case I saw a man that had the entire top of his scalp eaten away as a result of an injury some time back. I am not sure if it is a malignant transformation (marjolins ulcer), Leshmanaisis, or a chronic oseomyelitis. Either way it was purulent, oozing pus onto his shoulders and back, and painful. We put viscous lidocaine on it (Which did little), cleaned it, and I went to a pharmacy and bought him some cloxacillin. Perhaps it will do something to help but we had no ability to perform pathology or culture. It probably helped me more than him.
One of the problems we faced was cleaning some of these wounds. It was extraordinarily painful in the majority of cases. We have the availability of lidocaine and other anesthetics, donated by medical students from elsewhere, but in many cases the wounds were so infected and large that anesthetizing them was impossible. In other cases I have seen, I was reluctant to insert needles thru cellulitic tissue for debridement. So, I thought I would ask for some input from some of the more seasoned EPs out there. What is a reasonable area to anesthetize with simple infiltration? What is your philosophy on injecting infected wounds or thru cellulitic tissue. What about the wound margins? Some are keen on cutting away dead tissue from infected wounds with a scalpel, I have been more conservative.
I am aware that the anesthesia is less effective in acidic environments and I do not want to create wound tracts in infected tissue, especially where the infected area lies close to a bone. I would hate to create an ostemyelitis from cellulitis. I have looked into nerve blocks, and for some of the distal extremities, they are pretty straight forward. For the forearm or leg, or proximal extremities, they pose much more of a problem. I would like the ability to anesthetize the distal leg and forearm, but I am reluctant to perform brachial plexus blocks. What might be a minor complication in the US would mean death here. Of course, I have been told by Ethiopian physicians that they do not use local anesthesia or sedation at all, even during sutures or large areas of debridement. They do not generally have it available and do not view it as the standard of care. In fact, some Ethiopian students laughed at the suggestion of it. These were great students, but they have had no exposure to pain control.
So, any ideas or suggestions? Perhaps I'll just do what everyone has been doing, the best they can. For now my philosophy is "Primum Non Nocere."