Do Ottowa Ankle Rules work in Central America?

Due to my long blogging absense, I figure I owe you guys some fun stories of my trip. Story number one:

In the evening after dark, a 17 year old girl was leaving the clinic after socializing for awhile on our new concrete porch…(the gathering place for kids after dark who like to watch the gringos!) She tripped of the edge of the step hurting her ankle. I was in the clinic cleaning up the pharmacy when an OB/Gyn attending who had seen her first casually said to me, “Oh, you’re an ER doc, you should go see her!”

She was in obvious pain and I started to palpate (push) the bony areas prone to fracture. I talked (in bad Spanish) as I examined. Inner ankle pain free. foot pain free. Outer ankle…OUCH! she jumped off the bench and tears filled her eyes. I was impressed with how tender it was, and was certain she had a fracture. “Can you walk on it?” I asked her. Not even partial weight bearing.

We dug up some plaster casting material in the clinic and I used the opportunity to show some medical students how to put on a plaster splint. I also discussed with the attendings present whether we should send her for an x-ray. You’ll have to imagine the clinical setting…a rural mountain village of 1500 people, no electricity, only 2 or 3 trucks in the village that charge about 300 Lempera ($15) for a ride into the nearest town with a hospital about an hour and a half away down a treacherous dirt road. Fortuneately, this girls family owned a store and could afford “luxuries” like getting into town on occasion. I wrote out a prescription for an ankle x-ray and asked her to bring it back to us so we could read it. My main concern was whether or not the ankle joint was stable and would need operative fixation. As a 17 year old, if she had an unstable ankle joint that healed without proper repair, she would suffer from a lifetime of arthritis…not a good thought when you live in a village with only your feet for transportation. In special cases like this, if surgery were needed, we would take up a collection from the clinic funds or from the local health care committe that charges a nominal fee (about 50 cents) to be seen in our clinic.

Several days later, she comes back to the clinic, with no splint, and tells us the story: She had gone into town, gone to an x-ray clinic where they removed the splint (not necessary, but acceptable practice to get a good x-ray) where she was told by someone with uncertain credentials (was it a tech? a radiologist?) that she had a fracture and they sent her back up to our remote village clinic to have the splint reapplied. They did not give her the x-rays.

Basically, it was a waste of her time and money…I knew that she had a fracture and our question of how stable the joint is remains unanswered. A medical student reapplied the splint while I watched, and we instructed her to leave it on for another 6 weeks, at which point she could take it off any way she could manage. We left a week later and she was seen many times sitting in the sun on the front porch of her parents pulparia with her leg on a chair.

In developing areas, you can only do what can do. I hope she heals up well.

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