hot milk

9/10/16: I am drinking Radioactive milk!  I just couldn’t buy another can of Nido, the internationally famous powdered dry milk from Nestle which is found everywhere on the planet (even America). I have been drinking Nido for 6 yrs. now when I’m here and have never had a satisfying cup. However, it probably is responsible for keeping me alive with all its processed vitamins and minerals but it is not something you will ever crave. It’s just necessary.  So, this year I am trying irradiated milk from Europe.  No refrigeration needed, that’s a plus when there is no refrigerator. And it has an almost eternal shelf life even at African temps. It’s so ironic that Europe, which forbids GMO foods, allows its milk to be nuked and then sold in stores. But you know, it was good!  Just like milk back home and now my skin has a healthy glow…really. And last night I had a glass of milk before bed and I stayed warm all night. No sheet, no blanket needed; just my mosquito net. How bad could this be?  Really!

A Fractured Leg, A Broken Life

  To the reader:  Sorry to be so slow in posting. There are many stories, its the writing that is the hard part. This true story is from 2014. Attempts to follow up on the patient in 2015 failed. Now that I am back for 2 months I'll continue the search.


   After Sunday mass ( disclaimer: I go for the African mass music) I go visit a 28 yo man named Imani who was admitted during the night after a road traffic accident. He had a simple looking fractured tibia but now has a neurologic and vascular complication and cannot move or feel his leg or foot. His leg is massively swollen and I think he has Compartment Syndrome ( google that). I'm worried he will be crippled for life if I don’t do something or send him to Bugando Medical Center (BMC), 6 hours away on a bumpy road.  I discuss with surgeon on call. She has a rapid Swahili conversation with him. He has no pesa ( money), does not want and can't afford to go to BMC and  he also does not want surgery. And, just to complicate things I don’t think the surgeon wants surgery either. We will wait 18 hrs, I am afraid by then his leg will be too ischemic and he will be a one of those many dys-functional, handicapped people you see hobbling around here. This is the way it is.  I am familiar with the culture here. But I am still a visitor, still a guest. I can’t force or lobby hard here like I might be able to at home. If for no other reason then this:with my poor Swahili prolonged in depth dialogue with the pt or the family is impossible. And I am mzungu (white man).  We waited. I felt bad. Although I was not 100% sure Compartment Syndrome was the cause of his paralysis or that operating was guaranteed to make him better. I felt guilty for him loosing the function of his foot.

  The next morning with no improvement he changed his mind and agreed to surgery.  I took him immediately to the OR and with barely  sterile conditions we did a 3 compartment fasciotomy of his left leg.  By making 3 incisions down to and thru the fascia, the membranous sack that holds the muscle groups in your leg, it released the muscle which was swollen, engorged and dying because the pressure in the compartment was higher then the venous pressure. Since venous blood couldn’t get out, arterial blood couldn’t get in and the muscle was starving, dying. As soon as I cut thru the thin tight cellophane like fascia the muscle oozed out of its compartment like toothpaste out of tube. If you have ever traveled from sea level to Aspen you know what I mean. But in this case I had slit the tube wide open.  That muscle was necrotic and looked gray. Not the nice beefy pink you would expect. I reached under the wound and with a long scissor slit the fascia open inside, up and down the leg. We made 2 more incisions I opened the 3 major muscle compartments of the lower leg. Over the next few mins. the muscle started to pink up and ooze bloody fluid. It was over in 15 mins. That muscle was definitely under too much pressure. We did the right thing, the question was : were we  too late? We loosely packed the wounds and waited for the best. Besides sending him to Bugando Medical Center, there was nothing we could do but watch and wait.

   This is very hard for me to accept as a westerner. Maybe as hard for the patient to accept having a mzungu stranger tell him he wants to slice open his leg to make him be able to walk and feel his foot again. This is the part of poor country medicine we from the west have a hard time grasping. Sometimes there is no doctor, sometimes there is no nurse, sometimes there is no medicine. But sometimes its more simple then that. Sometimes there just is no money. There is no money for the hospital to offer “free” care. And there is no money for the patient, the patients family or the patients neighbors to pay. The result, Imani will be another poor crippled man. Another male who can not contribute to society, cant afford a family, cant pay taxes, cant contribute to an economy that wants to take off but is over burdened with uneducated, undertrained and thousands of crippled men. Men who despite their stupid behavior from fighting, drinking, and DWI cant get fixed and  then become the guys you see sitting around at mid day in every town and village,  crippled men. There is no Africans with Disabitities Act here.  The money spent on day 1 to take care of Imani would have been well spent compared to the lost productivity and social cost of another non productive male in this society.

    The fasciotomies helped but Imani’s lateral compartment never recovered. His leg swelling improved and the pain decreased but the muscle was irreversible damaged and the attempt to repair it was too late. I took him back to the OR 2 days later and removed lots of dead muscle from his leg. His calf muscle recovered but he never was able to move his toes or ankle.

   I found him a pair of aluminum crutches, a lucky break for him. There are no crutches here. People hobble around on a wide assortment of home made canes, single crutches made from branches or they have nothing. We don’t know this but this is how it was in the days before orthopedic and reconstructive surgery. Break a leg badly and you are a cripple for life. Break a hip and your bed bound for life or dead.

  Imani went home on day 8 with less pain and less swelling with 3 open wounds on a flexed dysfunctional leg with  his 2 aluminum crutches. He seemed happy to go home. Soon the realization will set in that he will not get better and he may still lose his leg. All because of unrecognized trauma from a” simple” fractured leg and no money to treat the resulting complications. The result: another broken life. That is the status of health care in this country today.