Sunday, December 21, 2008

Case #2: No Follow-Up. (Case Reports from Kijabe Hospital)

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians. For my non-clinical readers, use discretion before reading, and please excuse the medical jargon. 

Someone who read a previous post on my blog wanted to know what became of the young man who presented almost a week after an accident that left the mid-portion of his top lip avulsed. As much as I would like to report on his final post-operative outcome, and show you a picture of what he looked like in clinic when we removed his sutures, I cannot, because he, like so many patients, has not returned for his follow-up appointment.

SK is a 19 year-old male who was riding a motorcycle at a moderate rate of speed when a car cut him off. He went over the handlebars where he suffered injuries mostly to his face. This included a mandibular fracture, soft tissue injury/loss to the upper lip, and several small lacerations and abrasions. He was initially cared for at an outside hospital, where one of the doctors wired his teeth to stabilize the mandibular fracture. They made no attempt to treat the soft tissue injuries however, and after ~5 days, he asked to be discharged so that he could seek help elsewhere. He was seen on PTD #6, by myself in clinic where his injury was documented below.

SK's lip 6 days after the accident

He was admitted to the hospital, and brought to the operating theater the following day for debridement and repair. In the theater, he was found to have disruption of the obicularis oris muscle. The overlying skin and mucosa was raised off the obicularis muscle. The muscle was then approximated with several interrupted sutures. The overlying skin was then brought together in an “T” formation (see below).

SK's lip in OR after attempted repair

He was discharged the next day and instructed to return for suture removal, but he has not returned. Likely, he went elsewhere to have the sutures removed. This happens quite frequently at Kijabe Hospital where patients do not return for their follow-up appointment. Usually, it is just a problem of the expense and inconvenience of traveling all the way back to Kijabe hospital for follow-up care, but one can’t help but wonder if there has been some bad outcome in the time since you discharged them. Some take the attitude that “no news is good news”, and that if there is a problem, the patient will return, but I am not sure if this is true. Sometimes a no-show mean the patient was unhappy with their care, or worse, they are too sick to come in or even dead. Follow-up is very important for physicians to know if their treatment is effective, and when practicing with as much uncertainty as we do in Africa, the lack of follow-up is even more problematic. I had never fixed a facial laceration like the one on this young man, so I was anxious to see how it would come out to know whether my approach had worked. If a patient comes in with a similar injury, I will probably do the same thing, and be just as uncertain whether the repair will work. Experience should build confidence, but without follow-up, I remain essentially inexperienced and uncomfortable about how to fix the problem even though I have seen it before. I am learning that in Africa, I have to be comfortable with uncertainty.

Comfortably uncertain,

“Medicine is a science of uncertainty and an art of probability.”
~William Osler


At Mon Dec 22, 10:23:00 PM, Blogger Nikki said...

Hey Chad, From the pictures, his lip definitely looks better than it did at first. May God continue to bless you and those you serve and who are unable to be served there. We here are truly thankful for your service. God is being glorified! People are being healed! Keep the faith! You are still in our prayers. Love, Sis. Nikki


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