Accident in Obule and a whole day of just trying to get a poor guy stable. (watch out, this is a long medical post)

Last week Monday morning, 8am, found me headed through Obulle center on the way to the clinic for a busy antenatal day. Just before I got there, I encountered what was obviously a very recent accident. A truck had hit a piki, throwing both passengers.  I pulled over and ran up to the piki driver. He was unconscious, bleeding out of his nose and mouth, and had a very obvious femur fracture (a bend above the knee that I’m strongly suspicious wasn’t there before being struck by a truck). Before I got to him, two guys grabbed him under the arms and dragged him off the road. I asked them to please not move him (OK I screamed “Stop! Stop!”) but my yelling just joined the noise of everyone else yelling and neither of them seemed to speak English and by the time they understood me he was in the ditch on the side of the road anyway. As I ran back to my truck to grab my med bags I scanned the rapidly forming crowd (How is it in this place a horde can congregate in seconds?!)  for someone to assist me and get a bit of control. Thankfully, Emma, (here) grabbed one of my bags out of my hand and helped me through the crush back to the patient now thrashing on the side of the road. I asked him to move people back which he did quickly and forcefully. He also started talking to the patient in Ateso and brought a wonderful element of calm (well, slightly calmer which was still a huge improvement). My patient was now fully conscious and after being dragged his leg was straight so we were headed in the right direction, I guess. Sometime around this point the passenger of the piki staggered up to us, mumbling something. I had him sit down next to patient #1 and figured as he was walking and seemed at least alert ( though I was not ready to give him any orientation points) I figured I had a second to finish the other assessment. One minor thing that happened at the accident scene but I wanted to include thatI thought it was funny- I started to cut the pants on the guy with the broken leg and several people in the crowd around us became very vocal obviously horrified that I was about to cut his pant leg. They moved to start to unbuckle his belt and pull them down, which caused the patient to scream in pain and me to snarl something about backing off.  I exposed the leg before they could do anything else so they realized the pants were a lost cause. I’ll buy the guy a new pair of pants. Anyway, I was relieved to not find an open fracture or any bleeding. I explained that we were going to splint as well as possible and then load him into my truck. I would have given a full bag of M&Ms, well, maybe not that, but at least my firstborn child, for a backboard. But at least I had some SAM splint. Another funny side note, around this point the community had pulled the government nurse out of the clinic. He joined the crowd around us and started yelling for someone to bring cardboard. But then he realized what I was using the SAM for. He commented that it seemed like that was almost as good as cardboard for splinting. I pretended to not hear him and suggested he asses our other patient who was staring absently into space. However, the group around us was rapidly becoming a mob, very upset with the truck driver who hit the piky. So the nurse got distracted and left me to the medical work. I finished wrapping duct tape over the ACE wraps and decided both patients were both stable enough to get any other necessary interventions somewhere else. I told Emma to find a person who knew these boys and get that person to my truck. I directed 4 more people to lift the patient who I now knew as Richard and pulled patient #2 off the ground to follow. We all had to push through the crowd but rather quickly several people were in my truck, myself, the two bloody men and two others. By now it felt like there were 100 yelling people in Obulle center so I told Emma which hospital we were headed for and got out of dodge.  On the way into town, a 20 minute drive I was aiming to do in 12 to 15 minutes, I learned lots of things. 1. The patients were brothers and the elderly man in the back was their uncle. 2. None of these three spoke English. 3. There was also a lady in the car who works in the center and speaks English and is related somehow. (cousin?) 4. The 2^nd patient, who I never really assessed, whose name is Mark, remembers hitting his head on the truck and nothing after. He has a nasty bloody lump on the front of his head and also a dirt filled bloody abrasion on the side of his head so I’m suspecting he hit the ground and vehicle, both with his head and had a loss of consciousness for at least 2 minutes. Good news, he doesn’t think he has any pain except in his head. Unfortunately, this was all through his cousin as translator so I’m still not convinced he is fully oriented. 5 (back to the list of things that I learned on the rapid drive into town). Once we could get Richard to stop telling us of the pain in his leg, I learned he also has left sided chest and shoulder pain. This is the same side as the leg and the way the cousin describes it, this is where the truck actually struck him. In my head I can’t help but wish I was not the one driving and pray that he just remains hemodymanically stable for a bit longer.

Stole this from Bethesda's web page

I headed to Bethesda, which is my first choice hospital for several reasons. I really like two of the doctors (of a physician staff of three), the nurses are great and they have more resources than most other places in Soroti which unfortunately clearly still isn’t saying much. I pulled into the hospital and mobilized the nursing staff. They all came out to my truck and I sent one back for a gurney.  By now the patient is in excruciating pain.  We wrestled him out of the back of my truck (he wasn’t a big guy but healthy and solid, probably 80kg. Not easy to move into and out of the backseat) and wheel him into the hall next to surgery (they don’t have anything that resembles a trauma bay or even an emergency room.  This was as good as we were going to get.) I asked one nurse to start an IV, one to start a chart and one to go find us a doctor. I though how nice it would be go get him on a monitor but contented myself with a blood pressure. Thankfully, still normal. The doctor came in (unfortunately I got #3) and I brought him up to speed. He ordered pain meds. He did an assessment and we agreed that the patient probably had broken ribs and possibly a clavicle fracture but belly was soft and not tender. I started to explain to the family that he was stable and in good hands so I was going to head back to the clinic that I’d actually never made it to in the morning. It was at this point that the doctor looked up from the notes he was writing and mentioned that the x-ray machine wasn’t working and I’d have to bring them across town for x-rays. And not to bring them back after that as they don’t do traction here.  I’d assumed that the patient was headed to surgery but the doctor said traction was the best he would get in Soroti. Possibly Kampala if we wanted fixation. Well, I didn't like it but didn't feel like we had any other option so we tossed Richard back into the back of my truck and headed over to another clinic I know of that has an x-ray machine. No dice. Their machine was also broken down. So on to Joint Medical Clinic (JMC) in town. Where I'm not exaggerating when I say 200 people were waiting for lab, meds or x-rays.  And one of the things I hate about JMC is the it is right on Soroti's busiest road. With no parking lot. Which means we are unloading a patient into traffic on the busiest street in town. This place also needed 10 minutes to find a stretcher.
But while they did that I got the patient registered, convinced the desk clerk that we could skip the doctor and go straight to "radiology", which is just a dirty cement room with an ancient x-ray machine.  We waited a bit and while waiting the patient was getting increasingly restless, which seemed strange but I chalked it up to the fact that he was on a 10 year old stretcher. But as we waited it was obvious he was also getting a little tachypenic. He was struggling to sit up even though his cousin kept encouraging him to stay still. And now he was adding  occasional complaints of chest pain to his repeated complaints of leg pain. I have to be honest that I didn't put all the symptoms together but I did know that wanted to get him out of a hallway and admitted somewhere. We were taken back and had his pictures taken. It was again challenging (and painful) to get him off the stretcher and onto the table. As the tech shoved the x-rays into an envelope he mentioned to me that it looked like a slight pneumo. I pulled the slides right back out and could pick out the broken ribs and obviously comminuted clavicle fracture but as I have no formal training reading these things and the patients status confirmed his suspicion I didn't need further evidence. But we couldn't stay at JMC so we were off to my favorite place in all of Soroti- the Main Regional Referal Hospital. (OK, it is actually my least favorite place.)
Once again the patient went into the truck, loaded on busy main street, and we headed over to the hospital. By now the patient was obviously confused and uncooperative. I headed into the chaos that is Soroti Main to find a gurney.  We rolled our patient directly on to the ward where doctors were rounding so at least we got some attention right away.  The doctor that sauntered over took one look at our patient and told me that we would need to go get x-rays before they could do anything. I held up our envelope and started to give the run down. 19 year old male, accident, possible pneumo.... and the doctor wandered off. He didn't say any thing to me though he did stop and say something to a nurse who appeared to start a chart but I didn't know that for sure. I was tired and frustrated and at my wit's end with medical care (or the lack there of) in Soroti.
After locking the wheels on the gurney, and setting my bag down I headed down the ward after the doctor. I asked him what his plan was. He said he had not yet had tea (breakfast) and would be back right after to set up traction on the leg. I pulled out the x-rays and said, mostly nicely, that I would rather not wait as the patient was declining. Well, we had a protracted discussion about how the leg could probably wait but maybe a chest tube would be good. He finally came around to my way of thinking and told me he would mobilize the nurses to get things set up. So the gurney was pushed into a bed space and the nurse started doing her thing. She told me I'd need to run out and get sterile gloves, meds (like ketamine) and a few other things. This is normal for Soroti Main and I knew where I could quickly get the stuff. The nurse still had not done any vitals or even touched the patient for that matter but I left the family with some words to the cousin to keep a close eye on him and yell if he got worse. I headed back into town to get the supplies. When I got back it looked like nothing had changed. Neither the doctor nor the nurse was around. By this point it is past noon, and I've been struggling with this for more than four hours. I was not polite. I grabbed another nurse and snapped some things. She actually got a whole pile of supplies for the chest tube and started to set up and even got the doctor to come back. I had come back from the truck with some of my own supplies so took a set of vitals and pointed out to the doctor the patient was very tachy, and very short of breath. (I don't have anyway to do an O2 sat but I'm suspecting it was rather low). Thankfully he had a line in already and so we were pretty much set. The first nurse came back and I got out of the way. I felt really bad for the patient.  He did have a bit of ketamine on board by not nearly as much as he would have liked. But once the tube was placed he did breath easier. Literally and figuratively. So I headed out. He was transferred to a different city the next day as they decided traction wasn't going to be enough and he needed some internal fixation. But from what I've heard he is doing well, is home all ready and the family was very thankful. The reason that I'm finally getting this blog out is that I'm headed to tomorrow after clinic to see him so hopefully a better update tomorrow.