Il buono, il brutto, il cattivo – starring Clint Eastwood, Lee Van Cleef, and Eli Wallach
Working today at Kakumbi Rural Health Centre wasn’t really like being in a Spaghetti Western. The variety of clinical conditions cause me to feel joy, sadness, anger and despair, but this would not have been such a good title.
The Good. I have written about this little girl with sickle cell disease in the past. She had a nasty ulcer on her thigh which stubbornly refused to heal until we started daily wound toilet and dressing. Slowly, it began to heal. She stopped screaming when she saw a nurse or doctor because she could see how the ulcer was responding and she became my friend. I hadn’t seen her for a month or so, but she turned up today to get her monthly supply of folic acid (to help produce replacement red blood cells), penicillin tablets (to stave off infection) and anti-malarial prophylaxis (patients with sickle cell disease are prone to more severe attacks of malaria). Sadly, we have run out of folic acid (even for the first trimester in pregnant women), stocks of penicillin have been exhausted and we have never stocked Maloprim. She ate her breakfast while waiting for the pharmacist to tell her we had no drugs to give her and smiled at the camera. Isn’t she beautiful?
The Bad. This man was bitten by a hippopotamus three weeks ago. Bad because he was acting badly when he was attacked by the hippo. He is a very lucky man; most hippo bites are fatal. The wound was debrided and allowed to heal from underneath (by “secondary intention”). This needs a bit more tidying up and he will have an impressive scar, but he has lived to tell the tale.
The Ugly. Late yesterday afternoon, a man was fishing in Kapani Lagoon. He had probably bought “muti” from a sangoma – a magic potion which allegedly prevents crocodile attacks. It didn’t work in his case. He was bitten on the left leg and came to the health centre after normal working hours. Unfortunately, the nurse on duty sutured the main gashes and prescribed antibiotics which were not available.
Twelve hours later, he could not walk and had to be carried into the health centre. My colleague, the clinical officer who doesn’t like pus, asked me to sort him out. His leg was swollen and the skin was shiny and tight. The sutures needed to be removed. We have no scissors, so I had to do this with a pair of forceps and a scalpel blade. As soon as I snipped the first stitch, there was a mosi oa tunya (Victoria Falls) of putrid, orange-brown pus which burst from the wound. It stank so much I gagged. It reeked of rotting fish. Crocodile oral secretions are renowned for harbouring multiple pathogenic bacteria. I have never smelled a croc’s breath, but the pus probably smelled like crocodile halitosis.
The second wound I opened up had a different odour, sweet, sickly and fetid. The pus was watery and had bubbles in it. Looking deep into the wound, I could see the muscle had turned brown and black in parts. This is wet/gas gangrene, clostridial myonecrosis (dead muscle). This patient needed urgent surgical debridement, cutting away all the dead, infected tissue. Without a general anaesthetic, this is beyond my skill level. I knew that funds were really tight in the district and there was very little diesel left in store. We begged for an ambulance and were rewarded. I hope that I see him again before I leave and that his leg has been saved.
Because I am morbidly curious, I asked him how big the crocodile was. Like any fisherman, he extended his arms about a metre apart. “That small croc did a lot of damage,” I said. He replied, “No doc, that was the size of its head!”