Field Surgery in Madagascar (PG)

Before I commence with this blog post, I would like to issue a warning that its contents are extremely graphic, so Parental Guidance and viewer discretion are advised. If you are at all squeamish or uncomfortable with the sight of needles, blood or surgery, please do not continue.

Operation Wallacea operates with a medical officer at each of its research stations. This protocol is obviously required in order to ensure the safety of its staff and volunteers. One positive side effect however is that the operations bring highly qualified doctors into very remote areas, where such expertise is generally lacking. The local people take advantage of this service without much hesitation (it helps that it is generally free). Typically this means that the medical officer is inundated with mundane problems from the people around the camp, and our doctor, Karen, would be visited by the same individuals on a daily basis, each time complaining of different ailments with a variety of symptoms. Having a doctor who can render this kind of service can of course be beneficial on a small scale, and really does help those people with genuine and fairly simple problems. Less commonly, serious ailments present themselves, and it is on these occasions that having a qualified doctor is invaluable. Perhaps unusually for OpWall, Karen is a full-time practicing doctor in the UK, and therefore is able to perform surgical procedures.
Naturally, we thought, or rather hoped, that her surgical skills would not be needed or put to the test while we were in the field. This was not to be the case. On two occasions, local people came to Karen with serious injuries that required her immediate and full attention. Because I was acting as nurse in both cases, large section of the procedures shown here are unfortunately missing. However, I hope that what I managed to capture tells something of the story, and also helps you understand a bit of what it’s like to work as a field surgeon.

One day, a man walked into camp with a yellow cloth clutched tightly around his hand. He came over to the worky-worky, where our doctor, Karen, several Malagasy staff members, and I, were standing. He explained that he had badly injured himself to one of the Malagasy men, at first without removing the cloth from his finger. When he finally did, it was clear that he had badly cut his index finger. Immediately, we sprang to action stations. The medical tent was directly beside the worky-worky, so we were able to get the medical kit ready fast. Water was brought to clean the wound. Then we brought him over to headquarters – a small shady patch with a table and some chairs, some ten metres away from the bustle of the worky-worky. Karen set about preparing the tables for the procedure, placing paper down. Fortunately, the cut was a relatively clean one; Malagasy men are incredibly good at sharpening blades. It was not until the area had been set up properly, and the procedure was underway, that I finally had a moment to run and grab my camera.

The surgery begins.

The concentration is immense.

After inspecting the wound, Karen was able to establish that the cut did not sever any major muscles or nerves. She numbed the finger with lidocaine to make sure that the old man was comfortable. He was astonished with its effectiveness.

After the area has been numbed with lidocaine, the patient can’t feel a thing.

Passing the needle through the skin from one clamp to another.

The man watches as his finger is sutured up.

The cloth used to mop up blood and spread iodine.

The tools are set aside for later.

The wound required six sutures, spaced around the flap of skin.

Just one suture remaining. This, children, is what sutures are supposed to look like.

Sutures require extremely fine dexterity and a great deal of practice.

The final suture is cut

The whole procedure probably took about 45 minutes.

Betadine (Iodine solution) is used to clean the wound before and after sutures.

After cleaning, the finger is prepared to be bandaged.

The happy patient waits to be dismissed.

The man walked away with a full set of fingers. I am pleased to say that the wound also healed well, and although the finger may not regain full mobility, it will remain functional. This is the best outcome that could be hoped for really. It is difficult to imagine what would happen to this kind of injury were it not for the western doctor. Although there are traditional healers, trauma wounds are beyond their scope, and it is likely that they would either apply a tourniquet or simply amputate.

About a week after the finger patient showed up, a boy was carried into our camp on his brother’s back, his foot tightly wrapped in a blood-drenched cloth. Evening was just falling, and light was poor. As soon as he was brought in, we brought him over to the water barrel by the shower, and Karen proceeded to clean his foot. Fortunately, I had my camera near me when he arrived, so I was able to start taking pictures from the moment we first saw the wound. I asked him if it was alright, and started shooting.

The foot arrived extremely bloody and full of dirt – the boy had most likely walked on it for some distance before being carried to our camp.

It was immediately apparent that a great deal of cleaning was needed on the bloody mess that was his foot. I asked the boy and the people who had come with him what had happened. Although my Malagasy is not great, I was able to understand the gist of the situation: he had been cutting wood, and had slipped with the axe, landing it across the toes of his foot. He must have been some distance from help when it happened, for judging by the amount of dirt in the wound, he must have walked on it for quite some time before being brought to us.

The initial stages of the cleaning process, trying to get as much dried blood and dirt out of the wound as possible

The foot is then cleaned in a bucket full of filtered and chlorinated water.

The foot slowly gets cleaner.

Once the cleaning process was nearly finished, I ran over to the medical tent, grabbed the emergency kit, and went over to HQ to clear up the area. The boy was brought over by his brother. Before we let him be set down, we wrapped two planks in clingfilm, creating a relatively sterile surface on which to work. Karen set about preparing the procedure.

The box full of medical supplies is on hand throughout the surgery

A makeshift work surface of clingfilm wrapped around planks of wood is used to keep the area as sterile as possible.

Again, lidocaine was called into action to numb the area in preparation for the procedure that followed.

The doctor fills a syringe with Lidocaine for direct injection into the foot.

The lidocaine gets injected all around the wound, temporarily numbing the whole area.

The doctor checks to make sure that the area is numbed.

Unfortunately, because I was doing research in the forest after dinner, and my nursing services were no longer required, I had to leave the procedure at this point. However, the stitching apparently went well.

The cleaned wound, ready for suturing.

The boy stayed around for quite a while. Although he should really have been resting the foot, that is quite an unrealistic expectation in this kind of environment. Karen proscribed him antibiotics to help keep the wound from going septic. I am afraid to say I do not know how it went in the end, but soon he was running a fever and the wound was certainly infected. It is unclear whether or not he will lose the foot – a terrible loss in this environment. For more complete treatment, he would need to be transferred to Fort Dauphin, where he would be able to recuperate. That is an expensive prospect however, and many of the people in this area simply cannot afford it, no matter how great the need.

I hope this blog post gives you an idea of the great work that our doctor was able to do during her short stay in the field. Not only was she able to help these people in an incredible way, but she also enriched the lives of my colleagues and me, and was well loved by everyone. A great many people owe her their gratitude, myself notwithstanding.

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