The Travelling Pod | Treating partial nail avulsion

Here at the Vias in Irapuato Mexico, I have commonly treated people’s complaints of ingrown nails quite easily without any local anesthetic needed. However, there have been a few significant cases that have needed a partial nail avulsion (PNA) without Phenol.

The migrant journey (from South America) is very taxing on their body; from the Darien Gap jungle that includes days of river crossings through the Panama jungle, to days of walking in Guatemala and Mexico.

Patient conditions

To set some context upfront, the train cargo is different around Mexico. For example, in Irapuato it is often dirty coal. The migrants climb onto the train and sit in this coal for up to 22 hours before arriving at their next destination and repeating the process until they reach the border of Mexico. This means they are exposed to all types of weather and germs through their journey.

Therefore, I have to educate them on the signs and symptoms of infection and the ability to clean and maintain the wound from the procedure. I always provide patients with a ‘goodie bag’, with items like Betadine, gauze, tape for redressing, and gloves to cover their foot from their showers. Often, I need to use a translator to explain to the patient and one other family/ friend all the important details of redressing, avoiding moisture, signs of infection, and avoiding walking barefoot and trauma.

The perfect storm

I have never suffered from ingrown nail pain. However, when I did the migrant journey in the Darien Gap, I suffered from ingrown nail pain with redness and puss. This was no surprise, given the combination of the significant water exposure alongside the friction of the shoe which is influenced by our biomechanics. I never treated my ingrown nail infection by removing the nail because I knew the direct cause.

When I see infected ingrown nails, I understand how it can start, but I treat a PNA without Phenol because of its persistent nature. In a lot of cases, the ingrown nail signs and symptoms start in the jungle and persist until I see them two to three weeks later at the Vias.

Why I don’t use Phenol in the PNA procedure

There are many reasons why I would not use Phenol in the PNA procedure here at the Vias. Phenol as we know is effective but more invasive with a longer healing time. Also, the inability to safely store the Phenol, and the difficulty of educating the other workers about its toxicity, are two other contributing factors.

The patients I help, in using a PNA procedure can leave on the train at any moment. So, I have to communicate that once I start the procedure, I cannot stop even if the train were to arrive. Often, the next day I return to see that the patient has left on the train overnight.

Working conditions

A PNA procedure on the street at the Vias is very different from the clinic where I was working in Australia. The environment is a lot less clean, and it can be very different in general. There has only been one time working on the street where I did not feel safe because there was a man who was clearly on a substance and was showing signs of aggression. There have been other times when curious people, kids, and even street dogs come to watch my procedures. Commonly, I have had to move kids away because their eagerness to see is too close to my sharps for both our safety. Also, I am used to having half my attention on the procedure and the other half on my surroundings, with kids walking past or playing with balls nearby.

I have tried to pick the best location to do the procedure but it is hard to escape the hazards when you are doing the PNA procedure amongst people living on the streets. However, the benefit for the patient outweighs the risks.

To minimise the risk, on most occasions, I have had a helper who I know can be another set of eyes around me but also involved in the procedure.

Wind has uncommonly interrupted my previous procedures, causing dirt to blow into my clean area and equipment. This can be easily avoided working in the medical clinic at the Vias, however, it was not always appropriately maintained and it is used as a storage unit and shared with the doctor. Also, podiatry is not a familiar profession in the migrants’ home towns, and so they feel more comfortable with family and friends looking on during the PNA. Lastly, our feet are commonly seen as an unclean area and even more so when the patient is living on the streets and often walks around barefoot.

Sterilising process and equipment

One of the common questions I get asked is in regards to how I sterilise my instruments. I clean my instruments with ‘Clorox’, which is a bleach. The active ingredient, sodium hypochlorite, kills bacteria and viruses. Clorox is easily accessible and cheap, and so I clean my instruments using a scrubbing brush and then I do a second clean using alcohol and a baby’s wet wipe, and then I soak them in Clorox.

I have two general treatment packs with spare clippers stored away; one small tipped clipper and one heavy-duty clipper. When I first started in Bolivia, finding appropriate equipment was extremely hard. However, with the help of Sydney City Podiatry and Mona from Club Warehouse in Sydney Australia, I have received better quality equipment for better service.  Thank you to these sources of support, which makes my work in Mexico so much more effective.