Wound Care in Difficult Environments

[a_ditchdoc]

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."

 

[BKN]

Probably can't do a course in regional blocks here. "The Book" is Moore's Regional Anesthesia written a long time ago. A few principles:

1. No particular limit to the size of wound to be anesthetized by local except that of anesthetic toxicity (seizures,shock and death). Limit with lidocaine without epi is 5mg/kg. With epi is 7 mg/kg. 1%=10 mg/kg so limit for 70 kg man 35 and 49 cc respectively. Wait longer for field and regional blocks to take effect (15-20 minutes). If you must violate an infected field to get anesthesia, go ahead.

2. field block entire forehead is easy, just run a wheal of anesthetic all the way across the supraorbital ridges.

3. Debride all foreign debris and all dead tissue sharply. That is cut it back until it bleeds.

4. Open wounds properly cared for don't get cellulitis nor systemic sepsis. Easiest and lowest tech debridement is wet-to-dry dressings b.i.d. Get some roller gauze. Place a single layer down on entire wound, wet it with saline or water. then cover with 2-3 layers of dry gauze. Allow to dry and stick, then pull off to debride the wound. After a couple of days the wound will be cleaned up, forming a good granulation bed and ready to heal secondarily, or if very large to have a graft or flap.

Keep up the good work, bkn

 

[step1]

Good Posts
Just curious, are the dressings & instruments used well sterilized?

 

[BKN]

Good Posts
Just curious, are the dressings & instruments used well sterilized?

ditch can answer that. I doubt it. For open wounds it doesn't matter. clean is good enough. After all the wound isnl't sterile.

 

[a_ditchdoc]

Thanks for the advice BKN. I have in fact been using the wet to dry dressings as I could not think of anything else to do in the majority of cases. The only problem is the affordability of dressings for frequent changes. The dressings we have are either sterile or clean (American medical students brought limited supplies with them). One look at the patients and the idea of sterility is kind of tossed out the window, although we do try as much as possible. The problem with infected wounds is probably because most people live on dirt floors in a shack or their nearest street corner. Few of the poor people here have beds, so the dressings will get soiled quickly. Of course, we are careful about using instruments repetitively unless they are well cleaned as the HIV prevalence is very high here, especially in the population we are serving. We do have some sterile scalpels, needles, betadine, and scissors from suture kits as well as lidocaine and perhaps bupivicaine (marcaine?) for local anesthesia.

Thanks again for your advice. I'll try to debride these wounds a little more aggressively so long as it is tolerable by the patient. I'll keep you informed on how it is coming along.

ditch

 

[a_ditchdoc]

The wound clinic is not until tomorrow, but today I had the opportunity to work in the "emergency department" here. I was expecting a gritty inner city type experience with few resources and staff that ran around trying to deal with the various emergencies the best they could. What I found was quite different.

Outside I was greeted by throngs of people, all waiting for untold periods of time. As I was attempting to get the attention of those in charge, I realized that noone was...only an intern, who admitted he had no authority to make decisions. He was waiting for a more senior resident, whom he was sure would arrive within an hour or two.

In the waiting room, an elderly woman kept tugging at my sleeve and placing papers and x-rays in my hand. They belonged to a young man, 21 years old, lying nearby. She only spoke amharic, so I figured I could at least give them a glance to placate her. The images showed a very clear fracture/dislocation of C5-C6. I examined him, and found he was quadraplegic, febrile, and perfectly aware. I took a history with the assistance of a bystander. He was practicing karate and fell on his head several days ago. He arrived at the Addis ER 16 hours or more ago. I showed the films to a physician I tracked down, an orthopedist. He taught me how to relocate the dislocation and left facet fracture. He conceded that the best thing to do would to be do nothing and let him die quickly. I decided the crunchy noises when I popped it back in place would probably give me nightmares, so I sought an opinion from the only neurosurgeon in Addis. He told me not to relocated it, but to find the tongs for his head and place him in 13 lbs of traction. Of course, he had not seen the tongs in over a year, but they must still be around. He wouldn't actually go see the patient but he said if we could find the resident he might see him and help with the traction. I went back down to the patient. I explained the situation and informed him of the prognosis. He seemd to take it as well as expected. Another x-ray was shoved to me. It was a man, in his forties, with a large old bandage on his head. I figured, I'll just give them a glance. It revealed a large open depressed skull fracture that was comminuted down to the base of the skull, with obvious pneumocephaly (sp?). I asked how long he had been in the waiting room. "One Week" he replied. It was no misunderstanding.

I returned to the C-spine fracture. My classmate, with the help of a nurse, forged paperwork and signatures on paperwork, arranged payment for admission, and we then took him to the ICU. All was well...until..."We have no beds. Try transferring him to another hospital." We left him in the hall with the hopes that someone would eventually find him a bed. The man with the open skull fracture was missing when I got back. I assume he found a room...

The day has left me somewhat discouraged. Perhaps tomorrow will be better.

 

[Arctic Char]

from a 2nd year to a 4th year in the same program - i have to say thanks for sharing. sounds like a challenge, but its inspiring for sure.

best of luck mate. i have my fingers crossed for you and the rest for the match . . .

see you upon return

-p

 

[Annette]

Can your patients wash the bandages? Rags? Boiled- nice and clean.

There is an organization called AmeriCares, but you have to have a licensed physician to carry the supplies to the country. Also, check out vet supply and overstock companies for cheap supplies. When I was tracking down suture material for practice, I found medvet international. I don't have the web sites, but they should be able to find. I don't think they ship internationally, though.

 

[a_ditchdoc]

Annette,

Thanks for the input. As far as supplies are concerned, I am only here for for a limited period of time and having materials imported is beyond my current scope. With the proper money, many basic supplies can be purchased, but the need here is endless. My budget would not support doing very much. As it stands, I can only hope to help those individuals I come into contact with to the best of my ability. Many are homeless and have no ability to bathe themselves or cook their own food. Boiling bandages is out of the question.

ditch

 

[a_ditchdoc]

Yesterday at the wound clinic I met the gentleman with what I am still assuming is a squamous cell carcinoma that is eating away his scalp...or perhaps it is some tropical infection. I am hoping I am not missing some atypical leshmaniasis. Of course, I have no way of differentiating After a week of dicloxacillin he still had some exudate, but it is now much less and is blue/green. I am assuming it is pseudomonas, who knows. It is much cleaner than it was before and two small areas show exposed skull. He now complains of the smell, the smell of decaying flesh. I went to the pharmacy again to see what I could do for him. I looked for charcoal dressings to help with the smell...there was nothing of course. In the end I remembered a lecture from an oncologist and his experiences with liquid metronidazole on open wounds. He stated that it helped with the anaerobes that produced the smell. I could not find a liquid that I was willing to place on his very raw wound. I decided on metronidazole powder from caplets mixed with KY jelly or petrolatum. Also I found some charcoal tablets that are used for diarrhea/upset stomach. I figure we can crush them and place them in bandages to help with the odor. These will last for a week or so, after that he will be back to square one. In truth, we can do little to help him. I am hoping that my small gestures will relieve a small bit of humiliation or suffering until the inevitable happens.

All in all it was not a bad day at the wound clinic. Some of the wounds I saw last week had improved greatly with antibiotics and wet to dry dressings. One kid, in his mid teens, came in with an open wound on his tibia. Apparently he was fortunate enough to have had hardware placed to stabilize a fracture at some point in the past. He was unfortunate enough to have a chronic infection of that hardware that now leaves the shiny piece of steel and screws chronically exposed. His chances of having the metal removed are virtually nil. He will just undergo dressing changes until...until...well who knows.

It is amazing that the smallest wounds here are allowed to progress to such incredible degrees. I treated a man that had been scratching his shins from some unknown dermatitis. The excoriations became infected in both legs and were encrusted with a staph exudate that approached a half an inch thick in some places. I soaked them in moist dressings, applied peroxide, and eventually scrubbed them with a surgical scrub brush. It did very little and felt like I was washing an alligator. In the end I used the hard plastic part of the brush to scrape the wound and break the crust off in pieces until all that remained was a clean bleeding wound on both legs. Hopefully amoxacillin will help...it is all we had available.

 

[Arctic Char]

how often are limbs amputated?

 

[a_ditchdoc]

how often are limbs amputated?

Actually, through a combination of mismanagement and neglect, quite often. People with infections lose limbs, especially feet, without the aid of medical care. They just resorb or fall off. Just yesterday as I was walking along the street I saw a kid of about 12 hobbling along with rolled up x-rays in his hand. I took a look at the leg and x-rays and it was quite a severe case of osteomyelitis. I gave him some birr for whatever he might need to care for himself, although it was nice to see that he had already gotten antibiotics from somewhere. In the pediatric ward I saw two children, both in the ward at the same time, that lost limbs due to traditional practices. Traditional healers typically splint fractures with bamboo splints, and in the rural areas, they are often the only care available. Unfortunately, although they often have good success with this technique, people needing money sometimes call themselves "Traditional healers" and feel competent to treat people. As in the two cases I saw (about 3 and 7 years old respectively), the tight binding caused ischemia and necrosis of the extremities and they had to be amputated (one was a BKA and the other was below the shoulder). All from simple fractures. The three year old looked awfully pissed off over his missing foot.

What a place.....


See you soon,
ditch

 

[Red Beard]

As a side note, I was just reading about honey/sugar dressings and wound healing. One of those old folk remedies that has recently been brought under scrutiny and found to be efficacious, even for infected wounds that haven't resolved with other treatments. There is an ID doc at a wound care center down the road from me using this method. Kind of out there, but interesting I thought.

http://www.worldwidewounds.com/2001/november/Molan/honey-as-topical-agent.html

 

[Dr.Evil1]

Here is a good illustrated website that is free and accessible for learning how to do blocks. I'm sure you are doing all you can.

http://www.anaesthesia-az.com/article/509589.aspx

 

[Jejton]

As a side note, I was just reading about honey/sugar dressings and wound healing. One of those old folk remedies that has recently been brought under scrutiny and found to be efficacious, even for infected wounds that haven't resolved with other treatments. There is an ID doc at a wound care center down the road from me using this method. Kind of out there, but interesting I thought.

http://www.worldwidewounds.com/2001/november/Molan/honey-as-topical-agent.html

I am not an MD nor do i have much experience in this but I do find the honey tidbit interesting. Honey has been used as a preservative due to its biostatic or antibiotic? properties for a few thousand years in the Middle East. King Herod of Judeae embalmed his wife in it to preserve her beauty.

 

[a_ditchdoc]

The honey suggestion is one I have heard before. Unfortunately, honey is more expensive than most antibiotics, although in some ares they harvest it. Thanks to everyone that offered suggestions and advice during my time in Ethiopia. I read up on the blocks but fortunately I did not have to perform any. I had some success with local anesthesia and the GWU crowd was wise enough to bring local and 25-27 guage needles. Many of the wounds I saw improved with wet to dry, cleaning, and antibiotics. An exception is the squamous cell carcinoma of the scalp. An american physician there has managed to import fentanyl for him and is going to try to treat him, although the prognosis points to palliative care.

After spending some time in the emergency department, I have to say that I was shocked at the level of care available, or rather, the care not available. It is much less than is available here and the attitudes of the staff border on apathetic. I am sure it is simply a case of learned helplessness as the people there are for the most part very good people and seem anxious to learn. As a culture, they were among the nicest and most gentle of any I have known. Medical staff simply do not try to do their best for whatever reason. I was not there long enough to determine why. Perhaps part of it is because the physicians only get paid $150 per month, barely enough to live with any kind of of lifestyle. This is one of the reasons that there is only 1 physician for every 40-60k people. Only around 2k Ethiopian physicians remain, the rest leave for other countries as soon as possible, in search of an easier life. And while it is easy to sit at our computers from thousands of miles away and criticize them for abandoning their fellow countrymen, we do so from comfortable homes after a nice dinner of our choosing.

The need there is endless. People die in the waiting room, frequently. Nurses pulled the hair of one young lady because she moved as they were suturing a wound, a lid laceration, without anesthesia. It wasn't my place to say oterhwise despite how it made me feel. Once, an intern, the only phyician covering, left the emergency department for an hour or more for her lunch break. I happened to be the only one left to provide care for the people that arrived. On top of the hundred or so people gathering in the waiting room, an ambulance arrived with a multiperson MVC where everyone was bleeding from head wounds. What could I do? I did not know what limited supplies were available and certainly could not order tests, although they are sometimes available. I just assessed eveyone, gave suggestions to the nurses that were suturing, and made sure noone was dying. Damn, what a place.


As underdeveloped as the EM system is, the prehospital system is worse. The ambulances only carry an uncovered stretcher, a few bandages, and a bottle of alcohol. They told me they had a few hand tools for extrication but I never actualy saw them, depite looking through the ambulances. On a vacation to the remote Omo region, I actually considered picking up some IV narcotics in case of an accident. Jokingly, but only halfway, we also considered carrying potassium. I cannot imagine being one of the people that were cut from one of the many cars littering the highway. There were no phones in the south and most extrication was done by locals with hand tools. After you are extricated, then what? Perhaps they can get you to a local clinic. The clinic can look at you for a while as they consider how to get you to another hospital in a pickup truck. I can only imagine what the many kilometers of dirt roads feel like with an open fracture (hence the potassium joke). If you arrive still breathing, and happen to be lucky enough to have money on you, you may still have to wait up to 24 hours, or more, for surgery. In short, if your wounds are bad enough to kill you, they probably will.

It was a great learning experience. And, despite the grim picture, GWU is working to start a program for training people in EM within Ethiopia. It is an ambitious project, and certainly one that is going to give someone an ulcer. It is a worthwhile venture. I hope after I complete my residiency I might be able to contribute in some way to helping to develop both the hospital and prehospital areas of care. The bottom line is, without more investment from the government, or other governments, the health are system in Ethiopia is not going to improve and people are going to continue to wait 24-72 hours for emergency surgery and die within the waiting ares. Like any other problem, people become used to the way things are and stop trying to make change.

Thanks again fo all of your suggestions...