It’s Friday evening in Paoua and I will be leaving next week. Another surgeon will arrive on Monday and I leave for Bangui early the next day. My replacement and I should have the opportunity to walk around the hospital and see the patients together on Monday night. If she is jet-lagged, I may just 'sign-out' the service to her at the residential compound. Leaving a service and turning your patients over to another surgeon can be a tricky thing, best done face-to-face, even when you are just taking the weekend off and signing out to a surgeon whom you know well. And I am leaving for good and know nothing about my replacement other than her name. You might think it should be a straightforward process between two professionals but like all interactions between two people, human nature and our own point of view comes into play.
Last Sunday I heard that our medical chief, an internist ex-pat from the Ivory Coast, had accepted a patient in transfer from Bogila with gangrene of the hand. Gangrene can be either 'dry' or 'wet'. The 'wet' type can progress rapidly, spreading from the hand to the arm and leading to systemic sepsis within a matter of hours. Once again the transfer took over 24 hours and our patient arrived just before sundown on Monday. I went over to the hospital right away and heard his story.
He was a 25-year-old man who had suffered a burn to the hand and wrist one week earlier when he fell into an open fire after an epileptic seizure. The nursing staff had begun to unwrap the dressing on his right hand and forearm and they were all wearing masks because of the smell.
Once the dressings were off, it was obvious to everyone that this was a serious problem. His fourth and fifth fingers were charred and mummified though his thumb and index finger had been spared. The middle finger was questionable. Most of the skin on his palm was unburned and there was a healthy, two-inch wide bridge of skin from the base of his thumb up his forearm to above the level of the burn. But the back of his hand and the side of his wrist toward the fifth finger (the ulnar aspect for you medical types) was a disaster. The back of his hand had deep third-degree burns with exposed tendon and bone. As you followed the tendons up past his hand and arm, the burn was even deeper with widely exposed forearm bone at the wrist, with more dried out tendon and third-degree burns down to the fat on his forearm for the first three inches. There was a green slime covering half the wound and the unburned skin on his hand was swollen with edema. We gave him more pain medicine, quickly washed off the slime and re-dressed his wounds with gauze soaked in Betadine, an anti-bacterial agent.
I told the staff we would schedule him for another dressing change first thing in the morning at the Bloc under a general anesthetic. There I could do a more vigorous cleaning and a lengthier, more methodical exam to decide whether we could save his hand or not. I was almost certain he would need an amputation given the extent of skin and soft tissue loss, and the exposed bone and tendon, but as the gangrene was more dry than wet and was not spreading rapidly, I had the luxury of trying to come up with a creative solution overnight.
The exam in the OR the next morning confirmed that the injury was as bad, if not worse, than my initial impression. With the injuries to his tendons he would never have a functional hand even if I managed to save his thumb and first two fingers. I considered whether there was enough healthy skin over the hand and wrist that we could simply remove his hand at the wrist and cover the bone but after closer exam it was clear; he would need to have an amputation below the wrist. I suspect that if he had this injury in the US, where he would have access to hand surgeons with expertise in tendon transfers and microvascular soft tissue free flaps, he would still end up with the same amputation he would receive in Paoua. We redressed the wound, sent him to the recovery room and I went about the rest of our day in the operating room.
Later in the afternoon when he was awake, with the help of a translator, I told him that we would need to do an amputation the next day. The first step would be what is called a guillotine amputation where I would remove all the unhealthy, infected tissue and divide his forearm bones, the radius and the ulna, fairly close to his wrist. Four or five days later when I was satisfied that there was no remaining infection, I would revise the amputation, cutting off a few more inches of bone and sewing the skin and muscle closed over the stump. If I did the first amputation on Wednesday, I would be able to revise it on Monday and turn him over to the new surgeon on Tuesday, needing no further operations.
There are two schools of thought. One says that a surgeon who is about to leave should try not to leave work (by work, I mean an operation) behind for the next person to do. The other says that if you can put off the operation you should, thereby letting the next surgeon do the operation that he/she will be following up on. I generally subscribe to the first school although I never mind taking on an operation for a new patient, particularly if the previous surgeon was motivated by being unsure of what to do or was not comfortable doing it. To illustrate my point, on Monday, the day before I leave, I have plans to do a skin graft for a patient with a chronic ankle wound who I have been following. If I left the graft for the new surgeon to do, I would feel like I was 'dumping' my work on her. Most importantly, the patient’s wound is ready for a graft now and there is no good medical reason to delay the surgery for one extra day.
On rounds on Wednesday morning, our burn patient in need of an amputation said he didn’t want to go ahead with surgery. Overnight he had decided that he couldn’t go through with it. I sat on the side of his bed with the local docs and nurses helping translate everything into Sango. We reviewed why we couldn’t save his hand and the risk that waiting could lead to further infection requiring an amputation higher up his arm, or even a life-threatening infection. I told him about other patients I have treated in the US who said they would rather die than have an amputation, who were later glad to be alive. He seemed to listen and understand, but still said he didn’t want an amputation. Multiple members of the national staff explained it to him in their own way, trying to convince him but he remained adamant. No amputation.
I was not terribly surprised. The day before when we had talked about an amputation, he had nodded his head but his eyes had that look patients get when they aren’t really listening to your words. I have taken care of patients in the US who needed amputations and it is never an easy discussion or decision for the patient. We left it that he should think about our recommendations and we would see him the next morning. On Thursday his answer was the same. This morning he was still not ready to have an amputation although he has now agreed that his arm can’t be saved. His gangrene is not significantly worse but the smell has returned. I plan to push him harder to move ahead tomorrow as I am concerned that he could develop wet gangrene and lose ground fairly quickly over the weekend. But if I’m honest with myself, there are other reasons that I want him to move ahead with his decision for amputation. I feel like it is my responsibility to get this done. Amputations have always been one of my least favorite operations and I wouldn’t be surprised if my replacement also feels that way. Although I’ve never met my replacement and our paths may never cross in the future, I still don’t want to leave her with an impression that I have a bad work ethic and have simply passed this work along.
Often when it comes to hard decisions like this, patients in the US will ask me what I would recommend for my own family. Tomorrow morning, if he still wants to wait, I plan to tell him that I understand his not wanting to have an amputation but that if he were my son or my brother, I would tell him to go ahead with surgery now and not run the risk of developing more infection that could lead to a worse outcome. We’ll see in this case whether the bottom line in Paoua resembles the one in Seattle.
No matter what he decides, I will be leaving on Tuesday for Bangui. Rather than take the ICRC* plane, I asked to ride along in the weekly LandCruiser going south. Halfway there, we will meet another MSF LandCruiser coming from headquarters in Bangui with supplies for Paoua. We’ll off load the supplies from Bangui into the first vehicle. Then I switch LandCruisers and will ride the rest of the way to Bangui in the second car. It’s reportedly a monotonous, bumpy 11 hour ride over mainly unpaved roads. They say if I take a picture every hour during the trip it will be identical to the one from the hour before and the one from the hour after. But I am still looking forward to the trip. I guess I just want to see it for myself.
*International Committee of the Red Cross