A Tale of Two Knees

Ministerial Meandering

A tale of two knees

He was ‘Army’ - but nobody’s perfect - and an RSM (Regimental Sergeant Major), so in charge of all the squaddies, and with a remit to call them by whatever foul epithets he chose.  And you would have thought he might have known better.

His regiment was on R&R (rest and recreation) after deployment in Iraq, and now based in Cyprus - sun, sea, and all that goes with it.  But still nominally ‘working’.

He enjoyed wake-boarding; think water-skiing on one large plank instead of two smaller planks - like snow-boarding.

He had already dislocated his left knee whilst doing this sport a year previously, and following repair of his torn ligaments, told not to indulge in this activity again as his knee was no longer stable, and might dislocate again.

Unlike shoulder dislocations which are relatively easy to deal with, and apart from stiffness and a tendency to ‘go’ again, are not limb threatening.  Not so the knee joint; the main leg artery runs immediately behind the joint, and is frequently injured in dislocations.  This is a serious injury with potentially life-changing consequences.

Our RSM had decided he knew better than his medical team, and went wake-boarding again.  Needless to say, he dislocated his knee again, and landed up in the military hospital in Akrotiri in Cyprus.

Unfortunately for him, there was no-one there who knew what to do.  The out-going surgeon was an ENT specialist, and the only other doctor was a foreign orthopaedic surgeon.  You might think that was perfect - but no - he only operated on ‘cold’, elective cases, and didn’t manage trauma.

At this time, I was on a flight into Cyprus, to take over the surgical management of the hospital whilst the MOD (Ministry of Defence) in London decided who to send next.  So mine was a temporary appointment.

Whilst I was in the air, our intrepid pair of non-trauma specialists discovered that the RSM had no pulse in his foot, and realized that neither of them had the skills or knowledge to know what to do next.  So they arranged for our RSM to be transferred to the civilian hospital in Nicosia, where there was (apparently) a cardio-vascular specialist.

I arrived the evening of our man’s injury, and was told that he was now OK in Nicosia, and had been operated upon by the Greek specialist.  I unpacked and went to bed.

The following morning I walked into panic in the hospital.  The SSAFA lady (Sailors, Soldiers, Air Force Association - like a social worker, only better) had heard from the RSM’s family who were at the bedside in Nicosia.  Their man was in a huge amount of pain, and his leg was grossly swollen.

I commandeered the military ambulance and driver, and we ‘blue-lighted’ our way to Nicosia and the hospital.

Finding my patient, I saw a very unhappy man in considerable pain, surrounded by his equally unhappy family - and the tell-tale sign of coca-cola coloured urine in his catheter bag.  This almost always means massive muscle death with the excretion of myoglobin (which turns the urine dark), and impending renal (kidney) failure.

I moved his big toe a little - and he howled in agony.  This is pretty much diagnostic for Compartment Syndrome. We had a dire emergency on our hands if we were going to save his leg, or even his life.

I demanded to see the Greek surgeon; he was curt, and tried to reassure me that all would now be well.  I tried to point out to him that all was far from well, and asked to see his operative notes.

He had spent over 7 hours trying to reconstruct this man’s arterial injury, which he eventually succeeded in doing.  What he had failed to do was to relieve the pressure in the constricting muscle compartments of the RSM’s leg, with the result that there was now clear evidence of muscle death below the knee (Compartment Syndrome).  The operation had taken three times longer than it ought to have done, and had been inadequate.

My Greek colleague disagreed, but I wasn’t having any of it, and told him that the man was a serviceman, and therefore under my authority, and I was taking him back to the Military hospital.

We got him into our ambulance and once more ‘blue-lighted’ our way back to the Princess Mary Military Hospital in Akrotiri.

On the way, I explained to the RSM what had happened, and the significance of my clinical findings.  I warned him that I doubted I could save his leg, but I hoped we had got to him in time to save his kidneys.  I needed him to give me permission to go ahead with amputation if I found his leg muscles were all dead (as I expected), and not to have to wake him up to say, “I can’t save it - can we go ahead?”

He reluctantly agreed.  I then had to go through the whole thing again with his family who had followed us in their car.

I had radioed ahead and told the OR team to set up, and warned the anaesthetist we had a case that would likely cause him problems, as he was teetering on the brink of renal failure.

[Return for Part Two next week.  Believe me, there is a point to all this!]

Philip+