by Steve Badger, M.D.
Vanderbilt International Anesthesiology
Late one evening about 4 months ago, Josephine, a 31 year old Kenyan female, was riding home from a long day of work on the back of a motorcycle. An oncoming vehicle swerved directly in front of her to pass another vehicle. As the motorcycle swerved to avoid a collision she was thrown to the ground, severely fracturing her right ankle. She was taken to the hospital, where she underwent surgical repair of the ankle. Following the operation, she continued to have pain and weakness, to the point that she could not bear weight and had to walk with a crutch. After a repeat evaluation, she was referred to Kijabe Hospital, in Kijabe, Kenya, for ankle fusion.
Kijabe hospital, a mission hospital located an hour northwest of the capital city Nairobi, has a vast number of medical missionaries from all over the world serving the residents of the area and training locals in the practice of medicine and surgery. One of these missionaries, Dr. Mark Newton, is the only full time anesthesiologist in the region, and runs a training program for Kenyan Registered Nurse Anesthetists. The hospital, which is one of the most respected mission hospitals in the country, relies on donations of time, financial support, and supplies in order to maintain an exceptionally high quality of care. One such donation came approximately one year ago, in the form of a state-of-the-art ultrasound machine used specifically for the practice of regional anesthesia (peripheral nerve blockade). Ultrasound guided regional anesthesia is an advancement that is relatively new in the United States, and unheard of in East Africa. Though the overall resources and supplies in Kijabe are slim, hundreds of patients have benefited from improved post-operative pain control with the practice of peripheral nerve blockade, which involves injecting local anesthetics around large nerves of the arms and legs causing a portion of the limb to become numb. A single injection can last 15-20 hours, during which time it can provide complete pain relief following a surgical procedure. When the local anesthetic effect subsides, patients begin taking intravenous or oral pain relievers to control their pain.
Josephine, as mentioned above, had a severely injured ankle and was to undergo a very painful surgical procedure. We were readily equipped to provide excellent pain relief for her for 15-20 hours with an ultrasound guided peripheral nerve block, but we knew that when the block wore off she would still be in severe pain. Luckily, some supplies had just been donated to the hospital by Dr. Randy Malchow from Vanderbilt University Medical Center, including some peripheral nerve catheters, which allow the anesthesiologist to leave a catheter near a nerve and either attach it to a pump for a continuous local anesthetic infusion or give repeat daily injections through it while the patient remains in the hospital. Peripheral nerve catheter placement is an advanced form of regional anesthesia - many medical centers and university hospitals in the U.S. have yet to develop such programs - but through generous donations even a remote hospital in Kijabe, Kenya has the ability to provide this service in special situations, such as Josephine's. The decision was made to place a popliteal sciatic nerve catheter, which was done just prior to her going to the operating room. She then underwent operative fusion of her ankle. Following surgery, her ankle was completely numb and she had no pain. She was smiling from ear to ear because she remembered having terrible pain after her previous surgery. The following morning, her ankle remained numb, and she continued to have no pain. She was surprised at how well the nerve block continued to work. Later that day, she began to feel the numbness subsiding, and started to feel some gradually increasing pain in her ankle. A second dose of local anesthetic was injected through the nerve catheter that was taped to her leg and her ankle again became numb, with her pain disappearing completely. The nerve catheter remained in for 3 days following surgery, during which time she recieved one daily dose of local anesthetic and remained very comfortable, always smiling and thanking us for helping her. When the catheter was removed on post-operative day 3 and the numbness resolved, her pain was only mild and was able to be controlled well with oral pain pills. She was extremely satisfied with her experience.
It is amazing to realize that medical advances have progressed to the point that patients are able to undergo normally very painful surgical procedures with only minimal pain. What is even more amazing is that through incredible generosity by so many individuals these advances are able to be shared with patients like Josephine, living in a remote location such as Kijabe, Kenya.