“Head, Shoulders, Knees, and Toes” (read singing)

“Head, Shoulders, Knees, and Toes”

There are some weeks that the patients coming into the clinic develop a theme. “Oh, this week is head week” or “this week is foot week”. These past two weeks have reminded me more of the children’s song, “Head, shoulders, knees, and toes…knees and toes”.

(WARNING: Some of these stories, particularly the last two, may not be for the faint of heart! However, I do have medical or medically-inclined friends who want to know more about what we see in the clinic. These are a few of those stories, tamed down quite a bit from a nurse’s perspective but maybe not enough for some!)

Head:

First was a case of severe conjunctivis leading to a great deal of pain and discomfort in one eye. Not fun! Not sure why it started but the cornea showed damage and irritation and scleral edema (swelling in the white part of the eye) was present. Grateful that this missionary was visiting our center when this occurred and not out in the bush. We were able to see them right away!

Second was the continued follow up of a concussion. Though some affects continue, he was released to play sports again much to his great excitement! Yay for God’s healing! Brains and our nervous system are so complex that most of their healing is on their own and at their own speed. Our hands are tied and limited to treating symptoms as needed to prevent life-threatening complications. But really, we just get to watch God heal again!

Shoulders:

An elderly woman came in with a friend. The woman was hunched over a bit, huddled inside a fuzzy blanket, complaining of fever, cough, and right shoulder pain. X-rays showed that her right shoulder had no fractures or dislocations and that the pain was likely muskuloskeletal. After blood testing, it was determined that she likely had a respiratory infection and began treatment. In the meantime, while she was resting curled up on one our ER beds with the curtains pulled around her, I brought in an elderly gentleman with a dislocated left shoulder. He poked his head around the curtain to the woman laying down and spoke to her in tok ples (the language of their village) before smiling at me and saying, “Em meri bilong mi.” (“That’s my wife.”)

I led him to the next bed over and obtained his temperature, blood pressure, pulse, respiration count, and oxygen saturation. The doctor came in then and we heard his story together. So far as he could tell us, he woke up the day before with a dislocated shoulder and barely able to left his left arm. He thought it was just numb or sore from the way he slept, took some ibuprofen and rested it in a scarf sling for the rest of the day. The pain and limited mobility had continued since then. X-rays showed that the humerus (upper arm bone) of his left arm was a good inch or more blow the socket it should rest in.  With a lot of pain medication on board, we began the process of putting the joint back in place. After trying several maneuvers, all seemingly unsuccessful, another doctor was called in to assess. There had been no palpable “pop” of the joint back into place as is usual with replacing a dislocated joint. The patient still could not lift his left arm and continued to have pain, though he stated it felt better. (But better due to it being back in place or better because of the strong meds on board was difficult to tell.) Upon further examination by the second doctor and a second set of x-rays, it showed that his shoulder had indeed been returned to its socket but that perhaps the soft tissue (ligaments and tendons) surround the joint had sustained previous injury and thus were now “loose”, allowing the joint too much mobility. We immobilized his arm again, this time with a canvas sling with padded neck strap, and let him sleep off the pain medications that had been administered. We also were able to refer him to our in-house physical therapist. When he was again upright and mobile under his own power, the missionary took he and his wife and their friend home.

He now comes for regular therapy in order to strengthen the muscles around the joint and prevent future dislocations and injuries. His wife continues to heal from her illness as well though, since it has been cool in the mornings for the last several days, she continues to come wrapped up in her fuzzy blanket. They are a cute couple to see coming in and their shy smiles always brighten my day!

Knees:

Ok, so not exactly “knees” but a young man came to us for the first time this week after having sustained a bus naip (bush knife = machete) cut on his left shin. The cut showed some healing, being more rounded like a sore, but was reddened, hot, and swollen, showing signs of infection. We cleaned the wound well, dressed it with bandages, and described how he should care for it over the next few days. He was also started on antibiotics to help fight the infection. He lives on the other side of the river and comes by brukim wara (walking through the river (knee-deep to chest-deep depending on the currents and rain upstream)). We explained that he could not brukim wara again until the wound was fully healed due to the high amount of bacteria in the river water. There is a bridge further down, a little out of his way, but would be safer for his leg if he used that. He agreed and left with an appointment for follow up in a few days.

When he came back about 4-5 days later, the wound had not had much improvement in healing but the redness, heat, and swelling had greatly lessened. He said that it did not hurt much and that he had been faithful in doing the dressing changes every day. We changed the type of dressing applied in order to draw out the excess moisture of the wound and requested that he come daily for dressing changes the next 2 days. After 2 days of this dressing, we changed to a honey dressing that would remain on through the weekend. Hopefully, this combination will have the wound well on its way to closing but we shall see at his next appointment this week!

Toes:

(WARNING: This is one of the more descriptive stories!)

In the middle of a busy morning, we received a call from a bush missionary requesting to speak to a nurse about an amputated toe. I took the call and though the connection was staticky at times, the two missionary women were able to explain to us the situation, help us answer some assessment questions, and then receive directions for care.

A little 6-7 year old girl had been brought to them who had her right great toe cleanly amputated off with a shovel the day before. (Not totally uncommon due to most people being barefoot and using a shovel for most garden work.) A bush bandage of leaves and grass had been applied and the bleeding had stopped. In removing the bandage, they found a clean, straight cut that completely removed the toe. The bone tip was visible and the surround meat red without dark areas or pus. The wound itself was still quite dirty. Over the phone, we were able to talk the ladies through testing pedal pulses and capillary refill (ensuring that the whole foot still had good circulation), assessing tissue color (looking for signs of tissue death or infection), and any other openings or injuries to the foot. The only wound seemed to be that of the amputation itself without any signs or symptoms of infection. They were also able to email us a picture of the  injured foot, which greatly helps in assessment and deciding on treatment.(Hey, at least I spared you that, right?)

The little girl had already been medicated for pain before the phone call was made. Talking with the other nurses, we advised that the foot be soaked in clean, boiled and then cooled-to-warm water and soap, cleaning the wound well. Then apply some antibiotic ointment to the wound bed before applying gauze so that the gauze would not stick as bad at the next dressing change and further discourage infection. She should not bear any weight on the foot and definitely should not get the foot wet. We asked that the missionaries do the daily wound care so that they could monitor for signs and symptoms of infection and could ensure that clean water and technique for dressing the wound was used. The doctor additionally expressed concern over whether or not further surgical intervention might be needed in order for the wound to close with the bone piece still in place. We recommended that, if possible, they make arrangements to get her out to a surgeon and hausik (hospital) to ensure that sepsis or delayed closure of the wound would not become life-threatening. We are waiting to hear how she is doing.

Head, shoulders, knees, and toes! I’m glad we’re here to treat them all!