Buffalo attack wake up call, Medicine with AMREF in East Africa Dr Matt Edwards reports
That’s about as much information as filtered through into my brain as I answered the bleeting phone at 05:00 this morning. Before I was really aware I was not dreaming I had my trousers on inside out and was ineffectually attempting to fight my way out of my mosquito net in the darkness.
About 03:30 in the morning, a park ranger in a reserve close to Magadi, about 75km South West of Nairobi was on patrol when a buffalo attacked him. I am now reliably informed by my friends here that ‘Don’t worry about lions and snakes. Buffalo are one of the only beasts around here that will attack you for no reason.’ And they can cause some nasty damage. They are not as invariably lethal as the elephants but they will charge and impale you with their horns. This poor chap in question was charged before any shots could be fired. Apparently it dragged and threw him before attacking him on the ground and ran off into the night.
He was rushed back to the camp where the nurse there tried her best to stem the bleeding from the huge wounds in his shoulder, his thigh and his head. She did a good job with little equipment and established IV access and gave him painkillers and a tetanus shot. Throughout the ordeal he never lost consciousness.
before). As we took off into the dawn, Phyllis and I drew up basic drugs ready for a critically ill patient and very soon we were circling over the remote little airstrip in the Rift Valley. On ground we were greeted by a group of concerned looking rangers and staff from the park. Some of them obviously very shook up by the nights events. Others less so. I suppose, in general, there isn’t much to be worried about when you are carrying an absurdly massive gun.
We were all driven with our equipment through the bush to their camp and we were relieved to find a young man, in pain and bleeding admittedly, but conscious and orientated. The buffalo had managed to leave him without critical head, spinal, chest, abdominal or pelvic injuries. He had a few minor head wounds and a large thigh wound without underlying fracture. It had stopped bleeding and exposing it showed how very close the buffalo’s horn had come to tearing open his femoral artery. I doubt he would be alive if it had.
His biggest problems was a horrendous right shoulder injury. The animal’s horn had punctured through one side of the shoulder, shattering the proximal humerus bone as it went and torn through to the other side. Unfortunately he is right hand dominant. His pulse at the elbow was pretty weak but, amazingly, he had preserved sensation to his fingers and upper arm. The wounds were still oozing profusely and the arm was at a horrible angle. It was time to introduce him to my good friend Ketamine.
Ketamine is a fantastic drug for the pre-hospital environment and I think it would be one of your ‘must have’ drugs for remote medicine. It is ‘remarkably safe and is certainly the safest anaesthetic if you are inexperienced’ as, one of my old bosses Dr Sinclair wrote in his book on basic bush anaesthesia for AMREF ‘Ketamine is particularly useful in developing countries’. It’s a potent sedative, analgesic, bronchodilator and best thing about it is that you can give it to patients who had lost a lot of blood without their blood pressure plummeting. Most of the other strong analgesics and anaesthetics will do that, so you run a tightrope of cardiovascular instability if you use them in trauma.
It has its side effects of course. Some of you may know it as Special K for its exciting hallucinatory effects that probably make clubbing vaguely interesting. Those waking from the sedative effects of high dose ketamine often have crazy ‘emergence phenomenon’ which effect different people very differently. Last chap I gave it to, to extricate him out the back of landrover, stared at me and asked ‘Are you God? I am dead. You are angels’. Kids often have fun with their hallucinations but adults have a greater tendency to freak out. Children generally have an overactive imagination anyway, meaning that seeing a dragon at the end of your bed is quite cool, but as an adult you might start climbing the wall.
The other stumbling block for using ketamine in trauma is that the majority of the medical world thinks it will make patients’ heads explode. If you have sustained a head injury, due to a couple of case series written up in the 70s, ketamine is strictly not allowed as it was thought to detrimentally increase the pressure in the head. Making them explode! I’m not sure how many more review papers, head-to-head comparisons (excuse the pun) or research papers into its potential neuroprotective qualities in head injury need to be performed to revise the dogma. Doctors across the world are still far happier using drugs which dangerously drop blood pressure, an effect shown definitely to worsen outcomes in head injury, than use evil ketamine. It is so engrained into medical culture that I still feel uneasy about giving it. Not because I think it’s going to cause harm but more because of the stern criticism I can expect from other colleagues, utterly convinced I have made the patient’s HEAD EXPLODE!
We popped in another IV line, attached him to monitoring and I gave a mild dose of sedative in the vain hope that we wouldn’t get emergence issues. Then something a bit weird happened…
There is an old medical proverb that ‘if you hear hoofs coming down the corridor, don’t assume it is a zebra’. Which basically means, think of the common stuff first before rushing to weird and wonderful diagnoses. Real medicine is not like House MD, more’s the pity. So imagine my surprise as, having just administered the ketamine, I heard hoofs, turned round and was face to face with a curious zebra. It was watching me work as I knelt beside the patient. I had a double take, making sure I hadn’t inadvertently given the hallucinogenic drug to myself. ‘Nope, that’s a zebra alright.’ Now none of my medical mentors ever told me what to do if there is actually a zebra in the corridor. I pondered this for a second as the zebra and I stared back at each other. The surreal but beautiful little moment was broken as he was shooed away by one the rangers and we carried on.
I gave traction to the horribly crunchy upper arm as Phyllis applied a battlefield style dressing, splintage and a sling. The patient didn’t even flinch but I think his colleagues were slightly concerned by his fixed disembodied gaze at the sky. They do that. Soon we had control of the haemorrhage and the patient was packaged up and ready to move. We rang ahead to warn the receiving hospital that we had a limb threatening injury and to let their surgical teams know. With a 30 minute flight time we were in their emergency room in about an hour. The patient was taken for imaging and I understand he is now in theatre. Neither I nor the orthopaedic surgeon were particularly optimistic about the future function of that arm but, after all, stranger things have happened. Like zebras watching you at work for example.