Posted by Bibhusan Basnet
During one of our regular morning rounds, I saw an elderly lady carrying her two year old male child into the Emergency Department (ED). They were waiting to be examined and looked a bit distressed. I attended to the child. The lady told me that he had fallen from the stairs and showed me his legs. The child cried in severe pain even as I tried to check him over with caution. Quick examination showed that his right thigh was badly swollen, and it was clear that he required proper pain management before anything else. To relieve his pain, I ordered for some Ibuprofen syrup to be given to the child. I then recommended him for anterior, posterior, and lateral x-rays of his right leg.
Some hours later his x-rays were ready. “Right femur fracture,” Chanakya dai, one of our Health Assistants (HA) suggested as he examined the x-ray plate. I looked at the x-ray to be sure. He was right. The fracture was running through the mid shaft of the femur. Fortunately there were no displacements. The patient had to be put in a hip spica (see image below) without question. I asked Chanakya dai whether he had done such placements before. He happily explained that two weeks earlier, two US volunteers and emergency physicians, Mark Goodman and Angela McKellar, had taught them to put on a hip spica. However, neither he nor any of the other HAs in the hospital had independently done it before. “We usually refer such cases to Nepalgunj Medical College for hip spica placement,” he told me, and asked if I have had any such experience. Although I had assisted in placing hip spicas before, I could count the number of such procedures on my fingers.
Chanakya dai quickly expressed that few other HAs had also seen the procedure done by Mark and Angela. He sounded very eager to put the cast on the patient. With only a few case experiences, I was reluctant to do the procedure in the beginning. However, I knew that the economic condition of the patient was too poor and that the child’s family would never be able to afford him the trip to Nepalgunj for treatment. It was a “do or die” situation. If we couldn’t do the procedure in Bayalpata, the child risked living a crippled life. Deciding to go ahead with the procedure in Bayalpata Hospital wasn’t even an option, it was a requirement. The circumstances wouldn’t let us do otherwise.
I had mustered the courage to go ahead and was confident enough, but I also had my doubts as to whether I could actually make it happen. The doubt kept me on my toes and brought out the best in me. I gathered help from our other physicians, Dr. Ashok and Dr. Suman, to help me with the procedure. Given the lack of experience of doing such a procedure in the team, they too were reluctant in the beginning. But, given that we had no other options, we decided to have faith and trust in the skills of our team. The long distance the patient had travelled to get to us motivated us further to spearhead the procedure.
We then started to prepare for the procedure. Dr. Ashok looked for a video online on how to put a hip spica, to familiarize ourselves with the real procedure. At around 3 p.m., sitting by the emergency desk with our team of HAs (Chanakya dai, Ram bhai, Khadak bhai and Kriti ji), we (the three staff physicians) watched the video of putting on a hip spica.
After the video, we divided our jobs, gathered the 15-16 packets of 4 inch pop casts, and then asked the patient to move to the procedure room. We first made a support for the abdomen in order to prevent disturbance to the abdominal muscles and to facilitate smooth respiration. We wanted to give the patient the best care that we could afford with our limited resources. We didn’t want to leave any room for risk.
Our team proceeded with real energy and passion. We remembered to align the hip flex and to externally rotate to allow room for digression. With care and attention we made sure that the child could poop and pee without spoiling the spica. It really took us about half an hour to complete the procedure. It was indeed a very sweaty task.
After putting on the spica, we monitored the child’s vital signs frequently and checked for movement, color, sensation, and warmth in the child’s toes. We also taught the grand-lady to put some emollients on the genital area and told her about regularly changing the child’s position to avoid the dreadful bed sores.
We then ordered an x-ray once again to see if the bones were displaced. Luckily, the femur had no displacement and the child had no problem with respiration. It was an amazing and awesome procedure for us all. Chanakya dai was genuinely the happiest among us all. “No more referrals for hip spicas!” I heard him exclaim. I took a sigh of relief. He was right. Besides our team, the credit all goes to Mark Goodman and Angela McKellar, who were so awesome to have taught our HAs, this important procedure. If it had not been for their training, the child would have just been another case of our referrals that would have never gotten treatment owing to poor economic conditions. At the end of the day, it was an amazing success for our clinical team. The lady was also more than happy to have a definitive treatment for her grandson and it was written all over her face. Such successes are vital for motivating the staffs, and patient satisfaction is a crucial ingredient to keep adding fuel to continue our noble efforts in Bayalpata.
Dr. Bibhusan Basnet , MBBS graduated from B.P Koirala Institute of Health Sciences,Nepal. He has a special interest in Emergency Medicine and Psychiatry and is currently the Medical Director for Nyaya Health.