June 15th, 2013
I hated being in this position.
A young HIV-infected man came to our hospital in Malawi because of an abscess on his back. Actually, the abscess had been “incised and drained” the week prior at another hospital. The health workers there had “closed” the wound; that is, they had shut it tight with stitches, sewing up the entire incision.
Infected wounds should not be closed. It’s just basic medicine. The wound must be left open to drain and requires daily cleaning and “packing” with sterile gauze. This instance was not the first time I had witnessed this mistake.
The infected material had been locked inside the young man’s back. Since it couldn’t go up and out, it went down and in—into the blood. From there the bacteria circulated around the body, causing kidney damage along the way, and landed in the ankle joint.
My colleague had removed the stitches on the back. I lengthened the incision, irrigated with saline, and packed the space tightly with clean gauze.
There are two important points to mention here.
Firstly, I am an internist, not a surgeon. Although I perform lumbar punctures, most deep cutting and sewing is best left to someone else. Still, I am often pressed into service for lack of an alternative. Recently I drained TB-laden fluid from around a young man’s heart.
Secondly, because of donations, our hospital is usually well-stocked with basics such as gloves, cotton, gauze, saline and medicine. Most Malawian clinics lack even these basic necessities.
While holding the patient’s legs, the brother pointed out the ankle or “zotupa,” was swelling. An inserted needle yielded infected material. I groaned. It was already late. This abscess would also need to be opened. By me. Right now. If it were left to fester, the bacteria would again simply dive back into the body and pop up somewhere else. Medicines alone cannot penetrate into such dense infected tissue.
In fact, this “abscess” appeared to be within the joint, requiring me to pierce the thickened, inflamed joint capsule, remove the infected material, irrigate, and pack. I had actually never done this procedure before with a scalpel. That night it was just me and a nursing assistant, doing the best we could.
The next morning, the client was better, but still far from being out of the woods. The kidney failure could kill him. If there was un-drained infection deep in the tissue, that could also end his life. If we could pull him through this illness, he realistically has a chance to live decades given the antiretroviral drugs now available.
I have two roles. The first is as a doctor in a nation of 15 million people which might have 250 physicians seeing patients on a daily basis. In this country, there are very few trained surgeons. It’s even difficult finding a place to perform an appendectomy, much less proper drainage of an abscess in an HIV-infected client. Anyone who can afford to gets on a plane for somewhere else.
My second role is CEO of the African Mission Healthcare Foundation, one of the Watsi medical partners. AMHF represents a number of mission hospitals with strong surgical programs. None of those are in Malawi.
So, I get to see poor patients with both basic and complex surgical conditions receive quality care in Kenya, Tanzania and Ethiopia thanks to the generosity of Watsi donors.
But while in Malawi, I just have to wait, hope, and pray that quality surgical options will someday be readily accessible to the people of the country where I actually live and work.