Surgery in the field
The Virtual Doctors Work
Welcome, Malawi! After some targeted fundraising and hard work, at the end of 2018 a pilot of the Virtual Doctors service was launched in Malawi. The Clinical Officers have been sending in cases which are varied and challenging.
Since I started writing this blog, we heard the terrible news that Cyclone Idai has devastated many areas in Mozambique, Zimbabwe and Malawi. The clinics we support aren’t in these areas but our thoughts are with all those affected and we hope that the aid reaches them swiftly.
This month’s case comes from one of our new clinics.
Malawi is one of the smallest countries in the region. It covers an area of 118,000 square kilometres, one fifth of which is Lake Malawi. Lake Malawi sits in the Rift Valley which runs along this long, narrow country. Malawi is land-locked although it feels much like a coastal country with the lake down almost the entire east coast. It borders Tanzania, Zambia and Mozambique. A primarily rural culture, Malawi’s population still live in rural areas, however, recent problems like famines and high levels of unemployment have seen migration to cities increase, a shift we see mirrored in much of the world.
Malawi, like Zambia, is divided into 3 regions with 27 districts. Each region has its own capital. These are typically quite small.
The Northern region is the least populated. Its capital, Mzuzu, is tiny. It is the highest region, with unique highland areas and dramatic shorelines. It has one national park and one wildlife reserve.
South Malawi is the most populated and developed region. Blantyre, the banking and commercial capital, is found here, as is Zomba, the capital until 1975. Zomba sits at the foot of the Zomba Plateau and has forest trails, waterfalls and sweeping views over the surrounding plains. It is home to baboons and giant butterflies. There are 5 National Parks and reservoirs in the southern region.
The Central region is home to Lilongwe, the country’s capital, and is the most common point of entry to Malawi. Lilongwe has the national government offices, embassies and world organisations. Most of this region lies on the central African Plateau and sits at an altitude of 4000ft, but due to its gently undulating landscape it feels more like a plain. There are 9 districts in the central region.
In this piece we are visiting Lilongwe district. The district covers an area of 6,159 km2 (2,378 sq miles) and has a population of 1,346,360. The south west of the district borders with Mozambique and here is the stunning Dzalanyama forest reserve, created to protect Lilongwe’s water resource. The forest is a great place to explore –walking, trekking or mountain biking. The reserve covers nearly 1000 sq kms. The forest is an important habitat for ‘Miombo’ birdlife. (Miombo are the dominant trees here). The birds include rare species like the olive-headed weaver, Boulder chat and Black Eared Seedeater. The plants are incredible too with stunning ferns and epiphytic orchids.
Our case comes from Ukwe Rural health centre in Lilongwe district. Ukwe clinic serves about 35,000 people.
Virtual Doctors support 6 clinics in Malawi
A 48 year old man attended a busy clinic after having had a swollen right hand and arm for 3 weeks. He did not report any trauma but the family had thought it was an abscess so they incised it at home! No pus came out. His temperature at the clinic was high as was his heartrate. His other vital signs were normal. He was taking an oral antibiotic, erythromycin and some diclofenac for pain relief. On examination the clinical officer found the hand and arm to be in a bad way; swollen, hot and painful and very tender. It looked septic and fluctuant (squidgy). Some very helpful photos were included but I won’t put them here as they are a bit gruesome!
The Clinical Officer had started the man on intravenous antibiotics and asked for advice from our infectious diseases volunteer doctor.
The volunteer replied asking if the man was a farmer, as this would have implications in terms of the type of organism causing such a severe infection. He also asked for some clarification of signs. He felt it looked like an infection of the deep palmer space of the hand as the swelling appeared worse on the dorsum or back of the hand (as you would expect with this diagnosis). So this is an infection deep inside the hand which could spread to other areas such as the wrist and arm. As the most typical bacteria to cause this is Staphlococcus aureus or Streptococcal species, intravenous flucloxacillin or ceftriaxone (antibiotics) were recommended. The doctor also advised that an experienced person should perform an incision and drainage of the deep spaces of the hand, adding that the most experienced person available should perform it given the risk of nerve damage to the patient’s dominant hand. He offered to send the case to an orthopaedic surgeon for guidance on how best to perform the surgery. And he asked for feedback.
The clinical officer reported that the incision drainage had been performed and a whopping 40 millilitres of pus was drained. The patient treated for a while with IV antibiotics.
What is a Deep Hand Infection?
The hand is divided into many separate ‘compartments’ or ‘deep spaces’. Infection in these deep places in the hand is rare and very difficult to diagnose. An abscess (a collection of pus) can form in the muscle area at the base of the thumb (thenar space) the palm (deep palmer space) or the web spaces between the fingers. The cause is either a primary infection caused by a penetrating injury, even one that is very small, introducing infection, or from tendon sheath infections (the covering around tendons which allow them to stretch and not stick to the surrounding tissues). In very rare cases seeding of infection from the blood can cause the infection.
The most common culprit causing the infections are Streptococcus, staphylococcus and coliform bacteria. In people with compromised immune systems, e.g. those with HIV or on chemotherapy, unusual organisms may be responsible, for example an atypical mycobacteria.
Who Gets Deep Hand Infections?
It is a very rare diagnosis and in a world of antibiotics it tends to be someone who has had a finger infection that hasn’t been treated, or left for a long time before being treated; someone with diabetes, or who is immunocompromised or a drug user.
What are the signs and symptoms?
These can develop slowly and are consequently difficult to diagnose. Swelling, redness and tenderness of both sides of the hand with loss of the concave shape of the palm. There may also be finger rigidity and pain on trying to straighten particularly the ring and middle fingers. The infection may cause systemic upset too with a fever and the patient feeling generally unwell.
Some imaging, such as Xrays or ultrasound, may be useful to help locate the problem.
The aim of treatment is to control and stop the infection and maintain hand function by avoiding stiffness and contractures. These infections require both intravenous antibiotic and aggressive surgical treatment called an incision and drainage (to remove the pus). The hand has a highly complex anatomy, which is why an experienced hand surgeon is your best option. Sometimes a second or third incision and drainage surgery are required.
As these are closed spaces the accumulation of pus causes a rise in pressure within the hand which can compromise blood flow and cause ischaemia (lack of oxygen to reach the tissues) and subsequent death of the tissues (necrosis). The infection can spread to other areas, even to the wrist and forearm impacting nerves, bones and joints, even sometimes causing permanent damage. Contractures of the hand can follow infection resulting in a decreased active range of movement.
Aggressive hand therapy with passive assisted or active movements should be started when the inflammation has settled down.
It can be difficult to reacquire normal hand function after a severe infection.
Disclaimer: This article is for information only and shouldn’t be used for diagnosis or treatment of medical conditions. If you have any concerns about your health consult a doctor or other health professional.