I will never forget the day one of our volunteers put two and two together and realized that déjà vu is really a French phrase we Anglophones use all the time, literally meaning, already seen. He thought it was so cool he started putting together other deja phrases together, deja bu (already drank), deja su (already knew), deja pu (already could), and so on. We had such a good laugh over that. Well I had my own “déjà vu” experience yesterday.
The story starts 30 years ago at the Veterans Hospital in Dayton, Ohio. This is one of the oldest VA hospitals in the country, and one of the largest. It even has a civil war cemetery. Anyway, I was an intern at the time and one of the operations interns cut their teeth on is amputations. So my senior resident was walking me through a thigh amputation on this vet, and the time came to cut through the bone. We were using a gigli saw, which is basically like a strand of fine closely barbed wire that you use to saw through the bone. (I know now days everyone uses power saws, but I actually still prefer the gigli saw, it is faster and easier in my opinion). So I started sawing away. Now normally it just takes 30-40 seconds to cut through the bone. I got about a third of the way through and couldn’t get it to go any farther. My senior resident, Chuck Hardin, in good surgery training tradition, was yelling at me.
“Come on Scott, you wimpy old woman, get this done, saw through it, it’s not that hard.”
Man, I was sawing for all I was worth. Now I have always been the prototypical 198 pound weakling, but really this was ridiculous. Even though I was an intern, this wasn’t my first rodeo, not even my first amputation. So, I started sawing harder and faster. Sweat was going down my back, my glasses were fogging up, and I was dangerously close to perspiring into the wound. Finally Chuck grabbed the gigli saw away from me and he started sawing away. To my great delight he didn’t get any farther than I did. Finally after 20 minutes of trying to get the femur cut, we called for x-ray. Sure enough, our dear vet had undergone a previous intramedullary nailing. He had a titanium rod in his femur. This explained the difficulty getting through the femur.
I really don’t remember how we got that leg off. I lost the case, that much I remember, and of course was the butt of a number of, I thought, rather cruel jokes from my fellow interns. I think we called ortho and either they came in and took out the nail or gave us something to cut it with. For those of you wondering, quite reasonably, how we could not have known this guy had had an IM nail put in. Well, it was a hand-off error. He had come in the previous month and so the previous intern had done his history and physical, and either had not mentioned the previous surgery in his H&P or I had missed it when I reviewed the chart. Personally I am going with the former for obvious reasons. So, one of my many take home lessons from internship was, “Before you amputate, verificate.” And to my credit for 30 years I never made the same mistake again.
Fast forward now to early summer 2014. This very nice Arab man comes in at least a year following a very bad accident in which he broke his left lower leg. It had not healed well and so he had an extra joint if you will. This was in my internal fixation with plates days, before I started doing ex-fixes. And there was no way I was going to get a nail in his tibia. So I freshened up the bone got it together and got a plate on it. I will grant you it was really not a good job, but I never claimed to be an orthopod (still don’t). Well he did fine for the prescribed 10 days and then pus started coming out of his wound. Déjà vu, well the first one anyway, I had been here before. So we opened the wound, started wound care over his exposed plate, and gave him lots of antibiotics. The only other choice I had at that time would have been an amputation. He was with us for months. Abakar became a favorite, he was always happy and most of the time if one of the other patients didn’t have dressing supplies, he would open his bag and share. His situation was so horrible and yet although he was clearly frustrated and suffering he always had a smile and a kind word. For a Muslim he was a great Christian.
After some months, when his wound was stable and mostly closed we sent him home to continue dressing changes in his home village. He would come back every few months for a check-up and more pain pills. His wound never healed and continued to drain pus, as his wound followed that old surgical dictum, you can’t heal an infected wound with a foreign body in it.
My first day back at work after our forced furlough was Sunday. Abakar was on my office doorstep.
“Comment-allez vous, Abakar”, I asked. (How are you doing?)
“Ca va bien.” He answered with his trade mark smile. (I am doing great.)
“Comment va la plaie.” I wanted to get to the heart of it. (How is your wound?)
“Ca n’arrive pas.” He answered, still smiling, but less so. (Not so good, doc.)
That was actually an understatement, which is very Tchadien. It was awful. Several sinuses draining pus, wound open in the middle with shiny metal showing through.
“Docteur, j’ai souffert beaucoup depuis, depuis.” He told me. (Doctor, I have suffered so much for a long long time.)
“Je sais, Abakar, je sais. Je suis vraiment desole, mais tous ce que je peux faire c’est l’amputation.” I told him with tears in my voice. (I know and I am so sorry, but all I can do for you is an amputation.)
After suffering for over 2 years Abakar was ready. Amputations are such a big deal here, when a patient agrees to it, you know they are truly miserable. So yesterday Abakar was on the table ready for his amputation. I was able to do it just above the knee and so we had a tourniquet high on his thigh. We had prayer together and began the operation.
My first mistake was made about 4 minutes into the operation. With the tourniquet I could cut at will with no bleeding, so as I placed the gigli saw around the bone about 4 minutes into the operation I began mentally patting myself on the back for another fine job, (do not ever, ever do this during an operation, it is a guaranteed predictor of a disaster soon to strike). This was going to challenge my personal time record for a thigh amputation. I got the gigli saw around the bone and started to cut. Now rarely do I cut through bone with a gigli without remembering Chuck yelling at me 30 years ago. This time was no different. Except that this time his voice kept getting louder and more forceful as the seconds turned into minutes, and I wasn’t getting through the bone. Sweat was pouring down my back, my glasses were fogged up, I was dangerously close to perspiring in the wound. Déjà vu. But there was absolutely no way he had a nail in his femur. Only James Appel, Rollin Bland and I put in nails in Tchad, and I knew none of us had done it. So I kept cutting, and I made progress. Finally only a few millimeters left and progress stopped. So I did the good surgeon thing and just flexed his thigh and broke the femur the rest of the way. I used the amputation knife and the leg was off in another 30 seconds. As I separated the two pieces of limb I was face to face with, yea you knew this all along, an intramedullary nail sticking 6 inches out of his proximal femur.
Rebecca asked me what I did next. So I told her, “nothing, I just closed around the nail and left it. It would heal fine and work as a stem for a prosthesis.” Not even she bought that one. So I called for an ortho consult. Fortunately he was already in the room, in fact you might say we were of the same mind. Together we considered our options. We didn’t have x-ray so trying to find the proximal screw was going to be a nightmare, plus we noticed that it was not a solid nail. So maybe I could cut it. Bonne idée. But with what? All I could find was hammer and chisel, so Appo supported the nail and I started to beat the snot out of it. We made a little progress, but not a lot. By now I was going for the record for the longest amputation time. We finally decided to try our power bone saw. It worked for 5 seconds and developed an air leak. By the time we “fixed” it, well we really fixed it, I now have one air drill instead of two. (Anyone have an extra they would like to donate? Actually I need the air cord to the drill, the drill itself I think is fine, although a new matched set would be great.)
So it was back to the chisel. I kept checking to see if I was breaking the bone, but it seemed OK, so I kept banging away. To make an already too long story shorter, eventually I got through enough of it that Appo was able to break off the nail with our plate bender. We filed smooth the end and got it flush with the bone and closed his wound.
After I dressed the wound I looked at his thigh. Man I would never have found that proximal screw. For a race that typically scars with keloids, I could barely make out a scar. In the end I had made the right decision, and he should do fine. My take home lesson? “Before you amputate, verificate.” Hopefully I will go another 30 years before making that mistake again.
For those of you new to our blog please look around at the other pages, the “About” page tells a bit of who we are and our background, the “Definitions” page explains some terms that are used that some of you may not be familiar with, such as GC or AHI. The “Timeline” gives an idea of where we will be throughout the year, and the “Video” page has a video Bekki made of Koza Hospital as well as the videos she has made of Moundou. There is also the Surgical Pictures Page, but be forewarned, it has some very graphic pictures, so if you don’t like blood and guts, stay away from that page. You will also find links to other missionary blogs such as Olen and Danae Netteburg and others. Finally, if you like our blog and want to receive each new post directly to your e-mail, please sign up with your e-mail in the subscribe box. It doesn’t cost anything, there is no commitment, it just makes it easier to follow us.
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