It was an incident some 12 years back. I entered into the surgical ward in our hospital only to find a boy’s right lower limb in traction.I thought the child perhaps is suffering from some orthopedic condition.
It is learnt that my senior surgeon has applied the traction to the boy.History taking revealed that the boy had fever at least for one week followed by limping gait.He was unable to stand erect and had to bent at the right hip.This was due to pain in the right lower abdomen.Incidentally the treating surgeon also came in and told me about it.So I asked our attendant to release the traction and made the boy stand.There was a distinct bend at right hip as the boy was having pain.The limb can not be made straight even passively.There was a diagnosis in my mind.The boy was asked to to lay down and I palpated the painful site in the lower abdomen. My diagnosis was found to be correct as similar cases had been seen by me some time back.One hard lump was felt in the right lower abdomen nearer to the inguinal region.That was a case of psoas abscess.
So this is a sort of spot the diagnosis for the doctor if he had seen it earlier .The mind knows it.If not,the doctor is sure to be in darkness .Of course, now-a-days it has been made easy by ultrasonogram.At that time ultrasound was not available in those places.Had it been to-day I would have ordered for an ultrasonogram.My senior colleague was skeptical about the diagnosis.The treatment was to drain the abscess either under general or local anaesthesia.Once pus comes out the patient is bound to get a lot of relief.
We took him to the operation theater to drain it.The knife was with me.First, I palpated the most painful and prominent part of the lump.I aspirated the lump and scanty pus was out in the syringe.But my colleague did not appreciated that.Still I went ahead to make an incision on that part by knife.Then I took another instrument called sinus forceps to make a path to the lump from outside.Pus was not found .Again it was a victory time for my senior colleague . He tried to persuade me to abandon the procedure.But I did not move.I knew that the path of exploration was not right.I tried again and could reach the lump.A gush of pus came out under pressure to much the relief of the patient and of course,myself.
At that time only, my senior could appreciate that.So in medical science there are some diseases which are to be spot diagnosed .Now a days it is much easier.Diagnosis is to be confirmed by ultrasound and an ultrasound guided needle will invariably yield pus.But we lack the clinical confidence to-day.
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Many times people hurry to do something or complete some task.I call it busy for nothing.As for example people drive in a great speed in busy roads even without a head protection.Somebody runs in a busy and mechanized area to reach first.Specially if it is done in a work site of industry accidents are bound to to happen.One person ran to escape from being drenched in rain and fell down in front of a running train wagon and lost his arm .This is a typical story.And thousands happen on the road and in industries everyday.
A dis-articulated or amputated human body part can be re-implanted.This has some prerequisites.Apart from the resuscitation of the victim care should be taken to preserve the amputated part.A special solution is available to preserve the parts till one reaches the dedicated hospital with in a time frame.But those solutions are not available in rural set up.And consequently the amputated part decays.
But as we know cells do survive for certain time ,approximately 6 hours without oxygen.So when such parts preserving solutions are not available some indigenous fluid may work for some time.The part is to be cleaned with normal saline or a ringers solution.And kept in a clean sterile container if available, dipped in ringers solution widely available in medicine stores.That container be kept surrounded by ice packs .Then can be transported to a nearest hospital where the facility of parts re-implantation is available.
But the best is prevention of accidents and that is possible if one is slow and steady.
Some times some people do not avail a chance and let that go. A folk tale in Orissa,India describes how people ignore the opportunities.Once “Lord Shiva and His wife Goddess Parbati“were in the sky to observe the people of earth.They saw a poor man in skeletons begging for food but was not getting anything.Parbati became felt pity for him and asked Shiva to see this and also asked why people created by them should suffer like this.God replied to it with a smile that some do not like a grab an opportunity and are lazy ,consequently suffer.And He wanted to show that to Goddess Parbati then and there.The god put a pot full of gold coins on the road of the beggar .But the beggar at that moment wanted to mimick a blind man and walked closing his eyes.He gave a kick to the pot and walked past to open his eyes later .Consequently he missed the gold filled pot.Then the god asked his wife to interpret it and they went on the voyage.
Something of the sort happened to-day in our hospital.A person injuring his Achilles tendon came to me.Since ours is a private hospital only for port trust employees ,other people have to pay for the service with a token price only.I inspected the injury and asked him to deposit the required fees to get the tendon repaired .But the person expressed his inability to pay.I suggested him if he does not have the money he can pay it later also.He was not willing for that also.But on humanitarian ground I offered him to repaired it free of cost using material we get as physician’s sample but he has to get admitted to the hospital for some time.And to my utter surprise he declined for that and went away. Instantly my staffs reminded me of the story I just narrated.
The thick tendon through which the calf muscles get anchored to the heel bone is called Achilles tendon named after the Greek mythological hero Achilles.This is a tough tendon in the body.This tedon lifts the body weight off the ground while walking.
This tendon gets severed mainly by accidents,assault or in collagen diseases.When partially torn the person can walk limping and disability is more severe if completely torn.The person can not stand on toes of the affected foot.And if completely severed a distinct gap can be felt over an intact skin or the end can be seen if skin is cut.The upper end of severed tendon usually is dragged by the calf muscles to an upper level and may not be seen.Tendon repair is a special procedure and done under aseptic conditions .It can be performed under local.regional or general anaesthesia.The repair is done using a non-absorbable suture material.After repair a plaster of paris cast is given to immobilise the foot for 6 weeks.After that period a gentle physiotherapy makes the patient fit for duty.The results are good.
There is a clicking sound while clinching fist and pain along a finger of hand. This is a sort of spot the diagnosis for medical persons. This is a condition involving flexor tendons of fingers. There are tunnels and tendon pulleys in the fingers, made up of collagen/fibrous tissue .The tendon pulleys pass through the tunnels and work to flex the fingers while forming a fist. If the tunnels constrict or the pulleys thicken they can not pass smoothly and while passing along the deformed part it passes with a clicking sound .And hence earns the name Trigger Finger. If it progresses at one stage the pulley does not pass, so the finger can not be bent.
It may occur as a part of a collagen disease or without a specific cause. At the preliminary stage I advice the patient for physiotherapy under warm saline water. It relieves of the symptoms many a times. If not I infiltrate local steroid and lastly go for surgery to release the tendon pulley .The surgery gives immediate success. Under a local anaesthesia and skin crease incision the constricting portion is divided to release the tendon .Antibiotics and rest prescribed for some time.After removal of sutures a physiotherapy is advised.
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