In 2016 I smashed the bones in my forearm, developed osteomyelitis, and had a series of operations and procedures to return to normal. This is the second blog in the series discussing what I learned as a clinician – if you want to know how it all started, click here.
A little knowledge is a dangerous thing. If you’re going to educate yourself on your problem, don’t jump to conclusions.
Before my second operation, my partner asked me what the worst-case scenario was, given that what had happened so far had not been a bed of roses. I told her not to worry, but she pressed me further. She’s a sensible woman and she carried me metaphorically, sometimes physically propping me up, through this saga. In the weeks since the accident I had had plenty of time for catastrophising, so I already had my worst-case scenario. It was still a remote possibility in my mind, and I thought sharing a truly frightening story would put the lesser trials that were coming into context.
Well, I was wrong.
Because there had been a delay between the external fixation (where the metalwork protudes from the skin) and the internal fixation surgeries (where the pins and screws are hidden inside the body) there was a higher risk of infection. And with the fixation rods drilled into the bone, any infection carried a much higher risk of bone infection or osteomyelitis.
Osteomyelitis is a chronic infection of the bone that is tricky to treat. It’s tricky for two reasons. First, bone is comparatively avascular (meaning it isn’t rich in blood vessels like soft tissue). Because it doesn’t have as many blood vessels, it doesn’t see as much of the immune system (white blood cells, macrophages and antibodies) as other parts of the body, making it a good place for bacteria to hide.
Second, chronic infections have structure. Commonly, communities of more than one species of bacteria will build microscopic structures within their hidey spaces. At the centre there will be less oxygen and nutrients that the bacteria need to steal from the body. The bacteria in the centre will be relatively biologically inactive, just chilling out. This makes the bacteria at the centre of the chronic infection tough to kill. They are difficult for immune cells to find them because they aren’t making the tell-tale scent of biological activity. In addition, low biological activity (a sort of suspended animation) makes it difficult to kill with antibiotics as oxygen and respiration in the bacteria is required to be able to poison it.
Once established, osteomyelitis has a habit of erupting forth and taking over the area around it.
Chronic infections are scary not for themselves, so much as for the opportunities they present for other infections. We’ve all heard of sepsis and gangrene. The longer osteomyelitis goes on, and the more stress and damage caused by it, the greater opportunity for something life threatening to take hold. But it takes months of repeated failure to cure before it’s even possible.
So I explained this to my partner and emphasised that it would take months before I would be in any danger.
“What would they do if this happened?” she asked
Amputation is the way to definitively fix it, if things got out of hand.
Anyway, the second operation didn’t go as expected and there was a lack of communication between the operating theatre and the orthopaedic ward where my partner waited for me to come out of surgery. When I arrived, well after midnight, covered to the chin with a sheet, the first thing my partner did was pull back the sheet to see if I still had my left arm. Even high on morphine at that moment, I admonished myself at that moment for causing her the unnecessary anxiety by sharing my worst-case scenario.
But it goes further. I did get a post-surgical infection. And it did develop into osteomyelitis. And despite over a decade of study and years of clinical experience when it happened to me, I went the whole seven stages of denial, bargaining, anger (back to denial) rather than dealing with it in an objective (and therefore optimistic) fashion.
There’s the old saying that the person who represents themselves in law court has a fool for a client. Something similar goes on if you do your own diagnosis and prognosis. When it is yourself, there is a great deal of emotional bias that anyone short of Mr Spock will have a great deal of difficulty preventing from colouring their understanding of their condition.
I was never at real risk of amputation. It was as remote from me as emigrating to the North Pole. That is to say possible, but would require a series of improbable events to come true. But God, did I wobble when I had my worst suspicions that the wound in my arm was osteomyelitis…
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