When it Rains it Burns...and Turns Violet

It is June and already the rains are beginning to pound the coastal countries of West Africa. We have been in Sierra Leone for just over 3 months now. When we arrived in late February, the climate was akin to Chicago or New Orleans at the peak of summer, hot and humid and on some days…very hot and very humid.  The rains are a welcome change for many reasons, the biggest of which is, you guessed it, water. The lines at the water pump tend to be shorter since the rains have begun. The children seem to spend less time at the wells pumping water as the rains can fill all the containers at home to overflowing.  The air is also less smoky now that the rains put an end to farmers who, in the 21^st century, still insist on burning to clear farmland and prepare for cassava planting. But the rains also bring a few hazards with those refreshing showers, and I am not even talking about the cobras and vipers or the surge in pediatric malaria cases. I am talking about purple children. Purple children?? you ask? Well, let me explain.

The rains force the children indoors. The children who spent their entire day and sometimes a significant part of the evening outdoors wandering, collecting water, gathering firewood and sticks, ‘stoning’ mango, plum and other fruit trees for food, and otherwise foraging in the ‘bush’ find themselves having to spend more time closer to home or worse, at home.  It also means getting closer to the fire and being home when the piping hot food comes off the fire. Yes, here the cultural norm is cooking over an open flame. The stove is three rocks and a pot is placed over it. Some houses have a hut they cook in but it is still open flame cooking. The children who get burned often do from either reaching into the pot still on the flame or from the piping hot food spilling on to them. The story often gets lost in translation but the result is still the same – children with first and second degree burns covered in gentian violet.  Yes, that mainstay of wound care in many an impoverished and resource limited setting, gentian violet. While gentian violet has some great antibacterial, antifungal, and antihelmintic properties, there are better (and less messy) things that can be used. But here, if it is skin related then it calls for some purple haze and for burns and blisters, it is a whole lot of Hendrix. We had wounds that have healed long before we were able to wash off all that dye off the skin.

We currently have at least four children aged 1 through 6 that we are treating for burns. Thankfully all have been manageable within our scope and ability, meaning none of them worse than a second degree. And all are slowly healing with the help of frequent dressing changes, silver sulfadiazine, and the occasional application of Surgilube.

Before starting treatment. The burn is covered in gentian violet and black/purple eschar, so it is hard to tell the extent of the burn.

After about a week of treatment. Almost all the gentian violet has been cleaned off and there is good tissue starting to grow. The worst part of the burn is on his shoulder, but is healing nicely.

The Mystical, the Magical, the Miraculous…Surgilube!

Post conflict Sierra Leone. That is how it is still categorized 7 years after the last of the UN peacekeepers have left; many agencies and companies will pay you an extra stipend for coming to Sierra Leone, so I am told. But in the ‘town’ of Mokanji, southeastern Sierra Leone and in the heart of rutile and bauxite mining lands, at least on the surface, the conflicts seem to be confined to the water wells and pumps where some older kids feel the need to ‘flog’ a smaller child in line to fetch water or under the plum tree where 5 kids battle for one or two juicy plums that was knocked down after 30 minutes of stone throwing or ‘stoning’.  But in a society that still holds on to primitive farming techniques and venturing into the ‘bush’ for most necessities, cuts, lacerations and puncture wounds are a daily occurrence and often lead to major infections and even debilitating complications.

Once the word got out that ‘pumwae doctors’ (not sure how I feel about being referred to as ‘white’ although on a few occasions I have wished I was, but that will be for another post) were in town, they seemed to come out of the woodwork. Two week old machete wounds with gangrene, month old wounds with frozen joints and contractures and more than one injection site abscess from local practitioners whose answer to all maladies involve a ‘shot’. They all had the same story, “I having drinking the potion that the local medicine man has been giving me but I not getting better”. Or worse, “if I go the Freetown (the capital city) they will just amputate” The exact truth of this is unclear but I am sure it is somewhere in the middle with someone who went to the capital and ended up getting an amputation and the family’s reluctance to come up with the money needed to pay for the cost of transportation to the city.

It was our second week in Mokanji and my pregnant, yet eager and very OCD, wife decided to tackle and inventory the ‘Men's Ward’. For those who are not familiar with this place (and that would be all of you), it is part of the building that will eventually be the Men’s Ward and where most everything is stored, medical and otherwise, and we were eager to get a handle on what kind of supplies we had on hand. And that is where I discovered the nearly 500 single use packs of …that’s right…Surgilube, that very nectar of the Operating Room, that essence of sterility, that bacteriostatic potion that has saved the reputation of many a wayward surgeon.

Wound care has taken on a whole new dimension in this ‘rustic’ setting. Cleaning and keeping them clean is a monumentous task where ‘keep it clean and dry’ is not only easier said than done, it is often lost in translation. It is cost prohibitive and logistically impossible to do daily dressing changes, and semi-sterile conditions to do dressing changes, well it only exists in my dreams. So… Surgilube to the rescue.

Soak and thoroughly clean the wound as best you can and lather on the Surgilube. Apply dressing and tell the patient to come back in 3 days. It is a beautiful sight to see a clean wound on the first dressing change and granulating tissue with the second dressing change on a wound that was all dead tissue and pouring with pus just a week ago. 

Two inch injection site abscess with tunneling? No Iodoform gauze? No problem. Pack every three to four days with gauze soaked in… you guessed it…Surgilube. Three to six weeks and it is all filled in. Ten days of PO antibiotics doesn’t hurt either.

As my fame spreads to nearby villages, there is a down side...I am running low on Surgilube.

On a more serious note, please be praying for a 4 month old baby girl I am treating with a huge abscess from an injection to the right buttock (administered by local untrained ‘practitioner’ and an inappropriate injection site for a 4 month old) that was initially treated at a hospital 2 hours away but asked to find continuing wound care closer to home.

1 month old infected machete wound

One month later, thanks to a course of oral
antibiotics, frequent dressing
changes and Surgilube

This is just one example of how a round of oral antibiotics and frequent dressing changes can make a difference in a wound. While he has limited range of motion with 3 fingers, at least he still has his fingers and his hand!