Domingo, 19 Febrero 2023 16:27

Primum non nocere

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Bébédjia, 15 de febrero de 2023

Primum non nocere

Handicapes de Doba es el lugar donde acuden los casos desesperados, las deformidades imposibles, las heridas que no cierran, las osteomielitis indómitas.

Habitualmente se organizan una o dos misiones al año de traumatólogos franceses en Mondou, que es la capital económica del país y está a 65 km de Bébédjia. El problema con esas misiones es que los cirujanos solo conocen de antemano (si es que conocen algo) las fotos de las deformidades, la edad (al menos aproximada) del paciente y, en ocasiones, las radiografías, pero saben poco más de los pacientes a los que van a operar. Dónde viven (en una aldea recóndita o cerca de una ciudad), los medios económicos de la familia o el nivel educativo (a menor nivel, menos probablilidades de que confíen más en tu criterio que en el curandero). Ocurre eso y que el cirujano que intervino al paciente se marcha a los 10 días y quién sabe cuándo volverá.

Todo tratamiento quirúrgico debería ir seguido de las curas pertinentes, un periodo de reeducación y consultas de revisión por parte del cirujano. Algunos necesitarán material ortopédico y la mayoría alzas. Si no, la probabilidad de fracaso quirúrgico es altísima en países como Chad.

No basta con alinear articulaciones o dejar las piernas o brazos más « bonitos ». Hay que pensar en el después, aunque aquí se tienda a vivir el ahora porque mañana quién sabe si uno seguirá caminando por estas tierras rojizas.

Algo que se opera tiene un riesgo altísimo de infectarse. Recordad que los pacientes duermen, comen y descansan en el suelo. Que las casas no tienen agua, ni letrina, ni zona destinada al baño. Que aquí no se recogen basuras sino que todo se tira al suelo. El paraíso de los microorganismos, vaya. Por eso Jose repite hasta la saciedad: “mejor no tocar”.

Los tejidos cicatrizan muy, muy mal por la malnutrición endémica. La ingesta de proteínas es esporádica. Y eso, se nota. ¿Malnutrido? Again: « mejor no tocar »

Si te empeñas en enderezar, debes tener en cuenta que no debes empeorar la función que el paciente tiene. Tampoco el dolor. Y eso, que es un principio básico también en España, cobra una importancia capital aquí. De nada sirve tener una pierna más estetica pero dolorosa, infectada, más corta y/o menos estable. Además, hay que tener en cuenta otras cuestiones.

¿El paciente va a poder costearse las curas, la rehabilitacion, una ortesis o una prótesis?
Si no van a poder: “mejor no tocar.” Vas a empeorar la situación y a un precio muy alto: dolor, infección, menos funcionalidad.

Si tienen algo de dinerillo porque no se lo han gastado en curanderos, ¿Van a aceptar que se les ponga un yeso tras realizar la cirugia, van a querer hacer reeducación o utilizar la ortesis? La mayoría no, sobretodo si el paciente es mujer o un niño. Ergo “mejor no tocar”.

Es una gozada la valoración multidisciplinar con Jose aquí. El brainstorming que sigue al “qué se podría hacer en un quirófano”. Los pacientes se deben volver locos. Dos nasaras moviéndoles las articulaciones, explorando músculos, retracciones, golpeando los tendones con lo que pillen para sacar reflejos, haciendo que se siente, que se levante, que camine, vuelta a la camilla, otra vez arriba, abajo, exploro yo, explora Jose, y todo en un idioma extraño y a toda velocidad.

Conclusión en el 99% de los casos: “mejor no tocar. Rehabilitación”

El lunes entrará en quirófano uno de los pacientes a los que marramos el otro dia. El pequeño Mbaïadem nació con las piernas “invertidas” pero los músculos funcionan. Haremos unas tenotomías (articulación: mejor no tocar) para intentar que mejore su calidad de vida sin empeorar su función (de verdad, parece increíble que el pobre niño sea capaz de caminar). Pero no descarto yo que la misma mañana, al darle de nuevo mil vueltas al pobre, decidamos ser más minimalistas de lo que inicialmente pensamos.

Jose creía que poco iba a hacer con los medios que hay aquí y sigue pensando que no aporta nada, pero no le creáis cuando os lo diga. Está enseñando a Susan a hacer amputaciones (le quedan rebonitas), hace curas y suturas de heridas horrorosas en un pequeño quirofanito sin apenas medios, ha extraído dispositivos hormonales del brazo de una chica porque su marido quería tener más hijos (que cuatro no son suficientes aunque no pueda ni alimentarlos), operó un tumor axilar psicodélico, en Doba ha realizado tenotomias en camilla a la luz de las linternas, ha puesto (y enseñado a poner) yesos e incluso ha reparado escrotos. Habéis leído bien. Escrotos.

Pero lo más importante es formación que está haciendo sin darse cuenta.

No tocar.
Reducir fracturas e inmovilizar con yesos.
Si hay que abrir: la máxima asepsia que se pueda.
Y, después de meter mano, agua y jabón como si se acabara el mundo.

Creo que Jose está abriendo el camino a la nueva “traumatología sensata” en el país. Y si. Es una pieza imprescindible del equipo, aunque él no lo quiera (o sepa) ver.

Merci doc.

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