Discharge Advice

These pictures give a bit of insight to our operating room and some of the staff here that make generally 5+ major operations happen per day. Yesterday for example, it was three C-sections, a debridement of necrotizing fasciitis, an ectopic pregnancy, a D&C, a 20% surface area burn graft change which includes head and face, two arm fractures/casts and an ankle reduction. Without the people in these pictures, none of this would be possible... but these pictures have nothing to do with this post. I just want to brag about my team.

So often I give patients advice or counsel but easily forget about their reality. I recently discharged a young boy with a bad osteomyelitis infection in his leg. He had a chronic wound over his leg which drains pus everyday. X-ray confirmed the diagnosis. It was a usual presentation of osteomyelitis which is a fancy word for infected bone. It is hard to treat, especially in Africa. Bone is generally resistant to infection but once it gets infected, a part of it dies and produces pus forming a chronically draining wound.

As a surgeon, you can’t just remove it, at least not right away or you leave your patient without a functional leg or arm. In North America, we have an armament of antibiotics, special long term IV lines and surgical techniques and rarely do patients present with chronic osteomyelitis. Here, we have two antibiotics and I can’t afford for the infection to build resistance to them. Waiting is key. Over time, despite the presence of infection, healthy bone will separate itself and envelopes the dead bone while keeping the structural functionality of the limb. This process takes time, weeks to months. Once there is adequate separation and the healthy bone can support the limb, an operation can be performed where the dead bone is removed. Sometimes this dead piece of bone is inside the healthy bone and a hole needs to be made to pull it out as the healthy bone has grown around it. The wound and residual healthy bone is then left open to granulate in and with wound care it heals. It’s a lengthy painful ordeal for the patient but it works.

Until the operation though, the infected bone continues to produce pus which chronically drains. It sucks for the patient and I hate sending people home with chronic wounds but there is little else that can be done. I am working against a challenging illness, limited antibiotics, antibiotic resistance and also the financial resources of the family who generally can’t afford multiple operations or lengthy bouts of wound care.

To save the family money, I suggested they do some of the wound care at home. They live far from the the hospital and it was not realistic for them to come every day for a wound that won’t change much over the course of several months. I told them they could just wash it with water from a tap or a pump. It’s my usual wound care advice. Water from a hand pump or a tap can be expected to be reasonably clean. But, the father responded that they had neither near them. I asked them where they got their drinking water from. He replied from, “the river.” Sometimes I forget my patients' reality.

We discussed options and settled on the family using a pop bottle of clean water from a tap or pump to use for their wound care. They would have to get it from afar and bring it home. He will come back in a few months and hopefully the bone separation process will be complete so we can remove the infected bone and get his wound healed.

As the family walked off, I couldn’t help but think about life without running water. I realized in that moment how blessed I was to have water come out from 7 places in my house. Taps, toilets and a washing machine were things that this family definitely did not have. I wondered what illnesses they might get from drinking from the river.

Perspective is really important when giving discharge advice but it’s also important because it drives thankfulness in my own life. I couldn’t imagine living without running water… it’s just one of the many realities my patient’s face.

By Jesh