Wednesday, November 2, 2011

The great thing about wasman

Here everyone comes with at least 1 or 2 wasman (watchman).  They are like family members who might come with a patient to the doctor’s office or the emergency room in the US.   Most times in the US they are there for moral support, maybe helping to answer some questions, but that is about all.  Here in PNG wasman at times are put into service.

Tonight I got called about a pt in severe pain who had fallen from a tree and was thought to have a fractured elbow.  When I got there, the man was sitting calmly on the bed and the xray showed not a fracture, but a dislocation of his elbow.  Elbows, for those of you who don’t know – don’t easily dislocate.  Shoulders come out quite easily in some people (me being one of them).  They aren’t suppose to dislocate, but the head of the humerus kind of rests against the scapula with lots of muscles, tendons and ligaments holding it in place and allowing it to move all over.  Because it just rests against the scapula, certain movements with the right amount of force can easily dislocate a shoulder.  Elbows are quite different.   The elbow was made to really only open and close, like a hinge – not go all the way around like the shoulder.  This limited movement is a result of the big cup that the end of the humerus fits into to create the elbow.  It takes quite a force to move the end of the humerus from the cup of the elbow, but apparently a fall from a tree can do it. 

As I pulled out our 1950s DePalma Ortho book to look up how to reduce the dislocation, I looked around at my helpers.  There were 2 female nurses working in the ER, the female xray tech and myself.  Everyone is eager to help, but all are smaller than me and after looking at the amount of swelling of the pts arm and realizing what needed to be done, I wasn't sure we were going to be strong enough to get it back.  For those who want to know how to relocate an elbow, DePalma says one person needs to provide countertraction on the humerus back toward the chest/head while another pulls the end of his arm and then bends the arm at the elbow to put it back in place.  

I assigned one nurse to provide countertraction toward the head and I started pulling on the arm.  It was quickly apparent that this wasn’t working, as I was pulling the nurse with the pt toward me and I wasn't pulling the arm itself, so I stopped.  As I looked up, I spot the pt’s wasman standing there.  Bypassing the other trained staff knowing that strength is what I needed now, I ask him to provide the countertraction, which he was very happy to do.  He pulled one way and I tried to pull the other, but nothing happened.  So I look around again and find a 2nd wasman who had come into the ER – so I asked him to help me pull on the arm.  We both are pulling on the arm and then I tried to bend it up, but again nothing.  As I reread the instructions, I see it also talks about putting pressure on the end of the humerus that is dislocated and giving force down.  So I look up again and find our business office guy standing watching, so he too pulls on the arm while I stand on a stool to provide the force down on the distal humerus to get it back in place.  Still nothing, as the pt (under Ketamine) is yelling at us asking what we are doing as I try to bend up his arm.  At this point, the security guard who was standing around decides to help also.  So finally with 3 guys pulling one way, one guy the other and I pushing down on his distal humerus we got it in.  

So if you end up bringing a pt to the ER or even to see the doctor here at Kudjip, you never know what we may ask you to help with.