You never know what will show up to the Charity Accident Room when you are on call. I had been a doctor now for four months, doing a one month rotation in Plastic Surgery during my internship. Hand Call covering the Accident room was split between Plastics and Orthopedics. One month you covered male hands and the next month female hands. Male hands tended to be much busier than female hands with most of the fight bites, knife lacerations, and gunshot injuries occurring to the males. This was New Orleans, so sometimes there was a blur as to the patient’s gender. The basic rule at Charity: if you stood to pee –you went to a male ward. If you sat to pee—a female ward. It did not matter how you dressed or felt, it was the terminal plumbing that would decide if you were male or female.
Plastics was covering male hands this month. I got a call from the Accident Room about a patient with a swollen hand. It was a week day, middle of the morning…sort of early in the day for a hand consult…but like I said earlier, you never know what will show up to the Charity Accident Room. I walked into the treatment room and there sat a middle aged Asian man, he nodded and smiled. He was holding his affected hand inside his jacket, so I could not see it when I first walked into the treatment room. I have since learned, that if the patient is hiding his hand, that is a bad sign. I asked to see his hand and he pulled it out from under his jacket. Calling it a swollen hand was a huge understatement. This hand did not really look human, it was three times larger than his opposite hand and was covered with subcutaneous rubbery masses the size of marbles with little sinuses that drained yellow crusty fluid. I had never seen anything like it.
I soon discovered that the patient spoke absolutely no English. He was nice –he smiled and nodded to most of my questions. There were no interpreters at Charity, I was on my own. We played Medical Pictionary for the next 15 or 20 minutes. From our sketches back and forth, I had determined he was from Southern Asia (not sure what country). He was on a ship that crossed the Pacific, went through the Panama Canal, and arrived to the Port of New Orleans a day ago. I think the boat was carrying bananas, or something shaped like bananas, that was my best guess from his drawings. He was here to see the great doctors at Charity about his hand which had been getting worse over the last 3 weeks. I have been in practice now for 25 years, and this is still the furthest a patient has traveled for my care.
Now, I had no idea what was causing the swelling. I thought infection the most likely cause, but not sure what type of infection –definitely my first case of international exotic hand pus. First, I went back to the OR and talked with the Plastics Residents above me, they had no idea and told me it was my patient. I found an Ortho resident and he came to the Accident Room to see the patient with me. He looked at the hand and shook his head and said he was glad Ortho was on female hands this month, but had no real suggestions for me. All this time, the patient continues to smile and nod to me every time we make eye contact. He had traveled a long way for care at the Big Free, I was using all my four months of experience on this one. I cultured the drainage for everything and wrote admission orders. There was not a real abscess or fluid collection to drain –it was just hard edema from the wrist down.
Then I remembered that Infectious Diseases made rounds every morning at Charity. I found the ID team in the fourth floor SICU. As they were finishing rounds, I asked the attending physician, if she would take a look at an interesting case in the Accident Room. She took one look at the hand and called every ID fellow to come see the hand. My patient was now a celebrity. I bet there were 15 doctors that came to the Accident Room to see him. She took samples of the draining fluid and told me she would run tests on it and get back to me.
The patient had Madura Foot – except in his hand. This is a chronic granulomatous fungal infection caused by a thorn or puncture wound and is common in Southern Asia. Treatment was long term antibiotics, this case being sensitive to Bactrim. The patient had now been hospitalized at Charity for a few days. He was somewhat of a celebrity with lots of doctors and medical students coming by to see the international exotic hand pus.
The next day on rounds, I could tell the patient was worried about something. We played Pictionary again. His boat was leaving that evening and he wanted to go home. ID had told me that he needed to be on Bactrim for about 6 months. I found the drug rep that helped us give patients medication, mainly antibiotics, for discharge. I could not get 6 months of Bactrim donated, but did get a one month supply. Later that afternoon, my patient got dressed, covered his hand with his jacket, and left Charity carrying a large sack of Bactrim. I never saw him again.
The ID team published the case about Madura Hand. My name was not included as an author.
