On the 20th of July, it would be my 6th month here in Kosrae. And if you notice, there was a lull of about three months from the last writings I had in my blogspot. Practically, I got immersed in work and for one thing it is dizzying pace. I consider it as such because surgery work had been very busy. I am always confronted with the diabetic foot gangrene – operations ranging from simple debridement, disarticulation to below the knee amputation. It is often a long and arduous treatment process. If you do simple debridement or disarticulation, you still have to contend with the long process of waiting for the wound to heal. And sometimes during the waiting time, the patient ends up saying goodbye to the foot that they want to preserve. Conservative management is sometimes a frustrating treatment option . Sometimes, trying to preserve the foot upon the request of the patient becomes the radical option because one may think that the simpler option is just doing below the knee amputation.
BKA sometimes I feel is a way out for me and my patients. Yes, one may find it that way. The gangrenous infected stump is severed from the body. One may think it is easy as that and that’s it. But still, we have to contend with a lot of possible problems knowing fully well that these are patients who have poorly controlled glucose levels and have other complications, hence wound healing is poor. We encounter stump failure – wound dehiscence, wound infection and sometimes ascending gangrene. Just recently, we operated on a patient wherein we found out that she had a large thrombus in the leg. On the other hand, another presented with very sclerotic blood vessel. Ascending gangrene on the other hand is a very catastrophic complication as an operation above the knee amputation may be inevitable.
Diabetes mellitus is said to be a lifestyle disease among cosmopolitans. But I feel that among Kosraeans, it is a hereditary disease and it is very much associated with Syndrome X - high glucose, obesity, hypertriglyceridemia or hypercholesterolemia. And since this disease is fairly common among the Pacific Islanders and in one report has reached epidemic levels, it is as if, the islanders consider it as a part of their lives.
It is very unfortunate that there is no system for physical and occupational rehabilitation in the island. When they get to have BKA or any amputation for the matter, due to the physical disability the patient’s are terminated from work on medical grounds. When in fact, a lot of these patients can undergo rehabilitation – fitted with prosthesis, trained to walk like any normal people do – they can live a relatively functional life. If amputees can climb Mt. Everest, then why cant the diabetic patients with BKA in Kosrae. The government must look into the feasibility of hiring a physical therapist and an occupational therapist for the island state of Kosrae.
But unfortunately again, another problem is compliance. Most cases I saw would come back with another lesion on the previously unaffected foot. It becomes a source of frustration for a clinician like me who labored in saving a gangrenous foot from amputation and would find out that in the next follow-up, the other foot is affected. I wonder how our public health counterparts are doing regarding prevention and control of the disease. With data coming in, it should be a cause for concern because it has reached epidemic proportions already.
Of course, I would not just be busy with diabetic foot alone. There are a good number of cases in orthopedics. And this is very common to see in a cross-section of Kosraean society. I am not an orthopedic specialist. I only had some months of rotation in orthopedics. In medical school, our class monitor called my attention for almost a failing grade in orthopedics and I loathe the subject because I feel it is the carpentry of medicine. Pardon the pun. I don’t intend to offend the great orthopedic surgeons whom I have learned from. I could only smile in retrospect as I am faced with a good number of cases from clavicular fractures, shoulder dislocations to humeral, radio-ulnar, femoral and tibial fractures. Add to this are hand and foot fractures. Doing the casting and reduction takes a lot of strength. More so, when removing the cast, you need extra strength again. I told myself, I have to go to a body building gym when I get back for my 6 weeks vacation. Orthopedics has always been a challenge to me. Although not a favorite subject and rotation, I am always confronted by these cases and I have to face up to the challenge – by reading and applying what is needed to the patients. For complicated cases, I have to refer them off-island for further evaluation and management.
Of course, we are also confronted with an iota of the usual common surgical cases – appendicitis, hernia, exploratory laparotomy for acute abdomen cases. Since the Ob-Gyn specialist has not arrived yet, I still do the operations related to the specialty. It is here hoping that my load becomes lighter when the specialist arrives from the Philippines soon.
In all these cases from emergency to elective operations I deal with the patients with the best possible way. My being a perfectionist is both an advantage and a disadvantage. Advantage because we aim for the best if not an excellent quality care. Disadvantage because I am easily unnerved if things do not go my way. Although I must accept that there are inevitable things that happen like complications, most especially in a setting where poor compliance is more of a norm rather an exception to the rule and the limitations faced by the health system here in Kosrae, I do still try to make the best out of it under the present circumstances. I am glad that my efforts are greatly appreciated. Public feedback is very favorable it makes my heart leap with joy. I savor the appreciation of the people and they are enough to perk me when the flagging feeling – feeling of longingness, homesickness and boredom sets in. I feel I am not lonely but I feel I long for the people I love. These are some of the things you sacrifice when you make the decision of leaving some love ones behind.
