| Witnessing an amputation in a rural hospital

A U3 BSc student at McGill recounts his final experience shadowing doctors in India

This is the third part of a continuing series of Taran’s Health&Ed essays.

He was the last patient I saw at the KV Hospital in rural India, where I had spent five weeks between May and mid-June shadowing doctors. He was a quiet fellow – I don’t recall hearing even a single word from him – and he kept mostly to himself, even though his bed was in the busiest wing of the hospital.

He was a young man, no more than a year or two older than me, but he wore a pained expression that made him appear much older. It was an anxious, desperate look – a look to which I had recently grown accustomed, having seen it on the faces of almost every patient I met. This particular patient had his foot caught in a heavy industrial machine at work, mangling it to the point where it was no longer recognizable.

He had been rushed over by an ambulance from the site of injury. The on-call orthopedic surgeon, Doctor S., took charge. In an operation for which I had not been present, he attempted to reconnect what was now the two halves of the patient’s foot. Doctor S. had performed what is called a K-wire operation, a procedure that makes use of long, thin stainless steel pins to hold fractured bones together. In this particular case, he had inserted five K-wires through the patient’s toes, deep into the body of the foot. He had then bandaged the patient’s foot with several rolls of gauze before sending him to the recovery room.

As he was performing the K-wire operation, Doctor S. realized that the procedure might not work: the patient’s foot had simply been too badly mangled in the accident. This was confirmed one week later when he visited the patient, accompanied by myself and two nurses from the operating room.

We found the patient lying supine on his bed, staring blankly at the ceiling. Our entrance elicited no reaction from him, he continued to stare at the chipped white paint in the small square of ceiling directly overhead.

“Let’s take a look at your foot,” said Doctor S. The patient remained silent.

Doctor S. unwound the rolls of gauze. I tried to get a look at the foot, but the nurses were standing directly in front of me, and the room was too small to circle around for an unobstructed view.

There was a long silence. Then, in a very slow and careful voice, Doctor S. finally spoke.

“We’ll have to amputate it,” he said, more to himself than to anyone in the room. At these words, I automatically turned to the patient, whose face remained blank.

“Book the operating room (OR) for this afternoon,” said Doctor S. to one of the nurses. “We need to get this done right away.”

Then he turned to the other nurse. “Inform anesthesiology that we’ve got an operation scheduled for 12. Doctor C’s services will be required. Kindly inform Doctor C. that he will have to delay his lunch break until after the operation.”

As Doctor S. busied himself with the gauze around the patient’s foot, I tried not to think about what must be going through the patient’s mind, but my thoughts inevitably went in that direction. Here he was – a young man of twenty, watching a doctor wind bloody bandages around what remained of his foot. In two hours, he would be wheeled into the OR, where half of his foot would be removed. He would then be sent home with painkillers and a set of instructions about what to do if any discomfort persisted. These procedures, although important and necessary, still failed to address what was probably the patient’s most burning question: how will my life change, now that the operation is over?

I left the patient’s room with Doctor S., who instructed me to present myself at the OR around noon. When I got to the OR after having spent the rest of the morning in the patient ward, preparations for the upcoming operation were already being made: three nurses were busy unwrapping freshly autoclaved surgery kits, the cleaning staff was performing a last-minute cleanup, and Doctor S. was adjusting the operating table to the appropriate height. I left the room to change into sterile scrubs, and, by the time I got back, the patient had already been transferred from his stretcher onto the operating table. His face – formerly blank – was now anxious, and his movements were tense. Nobody bothered to ease any of his fears.

Doctor S. ordered his patient to sit up. Then Doctor C., the burly anesthesiologist, administered a vial of clear liquid into the patient’s lower back. He adjusted the IV line to ensure a continuous drip of fluid, and attached the leads of the cardiac monitor to the patient. When everything was ready, he signaled to the nurses.

A nurse carefully unwound three yards of bloodstained gauze from around the patient’s bare foot, enabling my first glance at the injury. When I saw it, I had to blink twice to confirm that the engorged and misshapen mass was, in fact, a human foot. The part of the foot past the heel was entirely unrecognizable – for one thing, the colour didn’t appear right. Upon closer inspection, however, I realized that I was looking directly at the underlying muscle; the skin had peeled off everywhere except for around the toes and at the heel. The muscle had a strange texture and appearance. It wasn’t smooth and bright red, but somewhat coarse and pale. His foot was a macabre patchwork of skin and discoloured muscle, crudely held together by five K-wires jutting through each of his five toes.

The first stage of the operation involved removing the K-wires. This was not a straightforward task: each K-wire was about six inches long, and had to be extracted from the bone. Using a pair of heavy, industrial-grade pliers, one of the nurses clasped the first K-wire and pulled hard in the opposite direction. It took her a quarter of a minute of tugging before the K-wire was removed.

Somewhere in the back of my mind, even though I understood that force was probably necessary to loosen the K-wires. it bothered me that the nurse wasn’t being gentler. This was, after all, an amputation – care and precision were likely not as important here as they would have been in, say, an appendectomy, the surgical removal of the appendix. Nevertheless, I still expected a certain degree of carefulness from the nurse – if only because she was handling the body part of a living person.

The nurse removed the next three K-wires with relative ease, and with each one, the top half of the foot got floppier, having nothing but stringy muscle left to anchor it to the bottom half. When she got to the last K-wire, she pulled and pulled, but it wouldn’t budge: after two minutes of fruitless pulling, it remained stubbornly in place.

“Let me have a go,” said Doctor S. He took the pliers from the nurse and pulled hard, setting his foot against the operating table for balance.
It took him half a minute of pulling to remove the K-wire. When it was out, the top half of the foot flopped over like a limp sock. Doctor S. used a pair of scissors to cut away the remaining shreds of muscle that bridged the two halves of the foot. In five minutes, the final attachments were severed. With the top half gone, the bottom half was now merely a stump, with slivers of bone projecting through skin and pale muscle.

Doctor S. discarded the top half of the foot into a biohazardous waste bag. The second stage of the operation involved smoothening out the stump of the foot. Using a pair of bone cutters, Doctor S. cut away the slivers of bone still projecting through the muscle. As he worked, bits of bone occasionally blasted into the air like shrapnel, hitting a nurse in the face. Each time this happened, Doctor S. would apologize profusely.

In fifteen minutes, the last remaining slivers of bone were removed, leaving the stump of the foot relatively smooth. The third and final stage of the operation involved preparing the stump for a skin graft – a procedure involving the transplantation of skin – which would be performed at a later date. Doctor S. sutured shut several leaky blood vessels, before carefully re-attaching loose patches of skin to underlying fat and muscle. The process was a painstaking one, requiring nearly half an hour of laborious suturing and re-suturing. Finally, the operation was deemed complete.

The nurses opened a fresh box of gauze and wound it carefully around what remained of the patient’s foot. The first few layers of gauze turned red with the patient’s blood, but, with each new layer, the gauze became fresher and whiter. Who could tell what injuries this patient had sustained, simply by looking at his bandaged foot? The most one could do was admire the outcome of the surgery – like the nurses, who had stepped back from the operating table to admire their handiwork, or the doctors, who nodded together in approval. Only two people in that room kept themselves out of the celebration: one was the patient himself, and the other was a young, somewhat naive outsider who, in his five weeks shadowing doctors in a remote hospital in India, had not yet acquired the ability to detach himself emotionally from the patient, and simply celebrate a successful operation.