Last night at dinner, this girl, Virginia, said, I’ll see you tomorrow! It old her that I was leaving in the morning. She asked for a gift to remember her by. I told her I didn’t have much (which was true, I packed ultra light, and brought no gifts) she asked if I could give her my necklace (I said no). I told her I would draw her a photo instead.
So I brought out this sketchbook that Kwin Krisadaphong sent me, and she asked for that as a gift. I showed her Kwin’s inscription and told her I couldn’t give away a gift to me.
I quickly sketched out this picture with a nice sketch pen I carry with the book. (She asked for the pen as well. )
I tore out the page and handed it to her after writing a message in both English and Spanish, then reached around to hug her and slipped the pen I to her back pocket. She pulled her shirt down over the pen so no one else would see.
It’s hard to want to be able to give everything to every child, but some of them somehow seem to make a bigger mark than others.
In Houston waiting for the flight to Pittsburgh now 4 minutes late. Plane pulls up to the gate. Me: “oh good, the plan is here!” Everyone around me: ” grumble grumble late grumble grumble”
Perspective people, perspective. You are all blessed with the freedom and income to travel. Unfortunately complaining and bad attitudes seem to be included.
I have learned so much from those who have fewer material goods than I do, but whom are far richer in extracting the most from each moment in life.
Safely arrived in Honduras, met our transportation to the village, saw many old friends already, it almost feels like home.
The Sun is setting, the breeze is cool, the kids at everywhere, the meal was great, the parrots are chirping and the strangest thing is there are lights coming on in the village.
2 years ago there was no electricity here at all, then all of a sudden electric poles went up, now lines and lights.
We have seen one patient already, a boy with a leg infection from a motorcycle accident.
This is a 3 part series
Read Part 1 Of Machetes and Snakebites
Read Part 2 Preparation Meets Opportunity and Betadine
Now Reading Part 3 Extensor Tendon Repair
We created the best sterile field that we could and numbed up the laceration with as much lidocaine with epi as was safe to administer. We had run the hand under running water to disrupt the clot, and then irrigated with sterile saline.
The distal tendons popped into view easily by simply extending all of his fingers flat against the table. They popped out like little white worms and just sat there. That was easy. The hard part was finding the proximal ends. I gently dissected the tissue back towards his wrist, grasping the overlying skin & fat in forceps then cutting the skin with a scalpel.
I was shocked when I saw a small whitish object hiding under the retinaculum. I quickly grasped it with forceps and pulled it out, placed a stich through it and kept it in sight. I tugged on it and his forearm twitched. We proceeded to suture the 3rd distal and proximal tendons together. While it wasn’t the prettiest knot, it was functional, and what’s even more important, his finger worked again!
THen I set off to find the 4th & 5th tendons. I had luck in only finding the smallest proximal tendon and I’m assuming it was the 5th. So I placed sutures through both the 4th & 5th distal tendons and sewed them to the 5th distal tendon.
In the end, I had a pretty three sided laceration…one side formed by the machete, and the other two formed by me looking for the proximal tendons. I pulled the two sides up and placed a red rubber catheter drain in the lac, and we created an ulnar gutter splint for him.
We fed both he and his brother dinner (tortillas, rice & beans) and the two set off towards home. We offered them a place to stay for the night, but they insisted on walking back home, 5 hours, in the dark.
The boy came back to the clinic 5 days later, after we were gone, to see the nurse. We received an email from her saying that the wound looked good, non-infected, and she removed the drain.
Hopefully in 6 months he’ll come back to the clinic to show us how well his fingers are working. It wasn’t the best tendon repair, but it was the best one he could get at the time.
Everytime I go there, I learn more, come back & study more and am better prepared. I can’t wait for my next machete wound in Hondura!
They hadn’t eaten since before starting work that morning and by the time they arrived at the clinic, it was late in the afternoon, the hottest time of the day.
This is when I met him for the first time.
“Doc Shazam, we need you. We have a machete injury…” said the 3rd year resident.
While minor trauma and fractures is run of the mill for me, the family practice docs that typically staff the medical clinic in the rural mountain village seem to find relief with my presence whenever the presenting complaint is trauma. So a machete laceration that is right up my alley is gladly referred to me by the other docs.
This was the first machete injury I’d seen on this particular trip. Usually we have at least a handful. It makes me wonder what the villagers do the other 48 weeks out of the year when there is no physician present, let alone an ER physician who is happy to poke around in tendons and muscles and such.
I had prepared myself for this patient’s visit more than a year in advance. 18 months ago, during my last trip to the mountains of Honduras, I had seen a similar case. A young man with a machete laceration, this one due to carelessness, and not a snake, had lost the use of his index finger. I performed a gentle and timid exploration for a proximal tendon without success.
Upon returning home I consulted with my unc
le, an orthopedic surgeon with over 40 years of practice. He’s very familiar with my global antics, even from before I went to medical school. I’ve asked him about the very situation I was now facing. Having never done an extensor tendon exploration or repair during my residency and subsequent clinical practice, I have since visualized the exploration I would do and the repair that would be needed.
When these boys and men have no other recourse aside from what they find at our clinic, how can I go wrong but to do an exploration, with the worst possible scenario that they recieve a sterile incision (due to my exploration) and leave with an injury no worse than when they came (only cleaner)
So the senior resident, 2 months away from starting her sports medicine fellowship and I began an exploration in anticipation of an extensor tendon repair. Others were skeptical…”Are you going to try and repair that?” they asked. “Why don’t you just send him down the mountain?” another questioned.
I knew that sending him down the mountain was an expensive proposition. First of all, he had no money for the ride down in the pickup truck. It would have to be gathered from the group of us, or deducted form the health committee funds, which are limited considering a clinic visit is the equivalent of 50 cents, which sometimes covers a family of six or more. This boy had no money at all.
Had I been assured that once down the mountain he would be able to see and follow up with an orthopedic surgeon, I would have given the $20-$40 dollars it cost to take an “emergency” ride down the mountain in one of the three pickup trucks in town. (More than a months wage for many people). But i knew that once he was in the Emergency Room in El Progresso, and had sat there for many hours, all he would get was a few superficial stitches in the skin, and he’d have lost the use of his left hand for good.
That was not an acceptable alternative for me. So, betadine in hand, bandana on head, and LED headlamp in place, I began my exploration for the extensor tendons of his 3rd, 4th and 5th digits on his left hand…
This is a 3 part series
Read Part 1 Of Machetes and Snakebites
Now Reading Part 2 Preparation Meets Opportunity and Betadine
Continue Reading Part 3 Extensor Tendon Repair
Tiled clinic porch in the tropical rain
I just returned from a 2 week trip to rural northern Honduras where muddy roads twist up steep mountain sides, and where farmers manage near vertical fields of corn and beans where mahogany trees once grew.
A fifteen year old farmer leaned over in the beating sun, swinging his machete in his right hand while gathering ripe corn with his left. His 10 year old brother picked up the ears that had fallen to the muddy ground. The older boy suddenly felt a cool touch on the back of his neck…followed by a slick sensation running down his left arm.
With an automatic reaction fueled by terror, the poisonous snake was killed with one swift swing of his machete. His left hand began spurting blood from the deep laceration left by the machete. The snake was dead, but he could no longer move the last three fingers of his left hand.
The younger boy ran to the edge of the field yelling for the other workers. The older boy stumbled down the hillside corn rows in shock, cradling his left hand across his chest. One of the older men doused the bleeding hand in gasoline to prevent infection and wrapped his hand in a towel.
With no choice but to maintain composure, the two boys began the five hour trek to our clinic where I met them for the first time.
Continue reading: Part 2 Preparation Meets Opportunity and Betadine
Read Part 3 Extensor Tendon Repair