Day 3 of clinic

On my third day of clinic, I was able to use my EM skills a bit more. The plan was for me to be in the women’s room where I could help see the infants and children. My first patient was a middle ages Kuchi women. I know have touched on the Kuchi people, and later I will hope to describe in more detail their appearance. Anway, this woman came in with complaint of body pains and mental illness. My gestalt was that she was a healthy person, and when you think about the life they lead – you know they have to be very strong. I was able to hold her hand and listen to her concerns through an interpreter. It sounded like sleeping was an issue, so I gave her some benadryl and Tylenol for her body pains. I then looked her straight in the eyes, touched her shoulder and smiled.


I was then called in to see a child who was burned. My EM mind started spinning and I grabbed some gloves. A Kuchi mother brought in a 4 year boy in her arms who was wrapped in a scarf. She sat down and put the boy on her knee. As she unwrapped him, the extent of his burn became evident. He had a large area of second-degree burns to his back and right upper arm. There was this bright orange something all over the dried burn. The history was that he was splashed with hot water 4 days ago. The orange stuff was a topical oinitment used in Afghanistan to treat burns. As I assessed his burns, I was initially concerned that his elbow was already becoming contracted in a flexed position. The whole upper arm was circumferentially burned and blisters already broken and dried. He had a strong radial pulse and his cap refill was good. I came to the conclusion that he need a good debridment of all the dried blisters. I tried to premedicate him with Tylenol and applied wet gauze to help soften the blisters. My plan was to let him sit for 30 min and then do it. Let’s just say, the best laid plans…

A staff came to me and said we have an emergency for you to see. Again I grabbed my gloves and followed. In another room was a woman sitting on a bed – frame, with piece of plywood covered with a sheet. She was holding her R arm out in front her, with her L hand on her shoulder. Her face showed she was in pain. I also noticed she had an IV in her R hand. Can anyone guess the situation? In the room was an Afghan female physician to translate, an Afghan male doctor who was treating the women, the woman’s husband, and another woman all dressed in black except for her face sitting at the patient’s side. I tried to get some history and quickly the volume in the room escalated. Everyone was yelling and I understood nothing. Finally I was told the woman had been treated in Kabul, given a prescription for IV meds, bought them and was to have them administered at the clinic. The male doctor and just given her the meds for asthma and she was having pain to her R arm. My differential was: drug reaction, infiltrated IV, thrombophlebitis, anaphylaxis and psychosomatic. She seemed to relay that her pain was worse in her shoulder. Looking at her hand – no swelling or rashes, pulse good, IV site looked good, no boney tenderness. Her whole arm looked normal. I then tried to palpate her shoulder and she whelped. I then moved her through ROM and she had not difficulty. By this time, my overall impression was there was nothing physically wrong with her. I have had a few clinical encounters with Islamic women and sometimes there can be a bit of drama. Anyway, multiple verbal exchanges at a yelling volume continued and I tried reassure the patient. Through the interpreter, I told her her arm was good. I tried to think of some of the interventions I had available to me at this time that might help the situation. How about taking out the IV and some Tylenol/ibuprofen? I took out the IV and placed a big blue band-aid on it. As we gave her a couple Tylenol and ibuprofen, she swooned and laid down with her arm across her face. We were told she had a reaction to the medication. Confirmation for drama! Her husband now was yelling, grabbing her hand and trying to pull her out of the clinic. She had a good pulse, no respiratory distress and good color. Again I tried to reassure the patient that she was OK. After a few minutes of hand holding and smiles, she got up and walked out. Apparently she was cured!

Back to the burn boy. We moved into their ER – literally a room, and I began to take off the dressings. Unfortunately the wet dressing had now turned dry because I had spent too much time with the other woman. I was hoping for soft skin to help the process. I tried to explain to the mother through the interpreter what I was about to do. With lots of water and gauze, I did my best to remove the dried blisters. I felt just terrible as the little boy screamed because I had nothing better for analgesia than the Tylenol I had given. Mother was really good at helping hold him, but it was a moving target for sure. Once I had the hard, dried blisters removed, I tried to extend his arm gently and slowly. I can only image the pain. I held his arm in extension for a bit and then released and repeated. I had the mother demonstrate the same, because I knew with some PT, the boy would have significantly decreased function of his right harm due to contracture. Mother was wonderful! I replaced a dress of Xerofoam and gave the mother enough to do daily changes. Supposedly the little clinic we were at had a burn clinic and we instructed them to return in 2 days for a check. I truly have no idea what kind of prognosis this boy with have with his arm, but I pray the best for him.