Tanzania

By: Chirag Shah, MD

“Primum non nocere”- First do no harm. As a training orthopedic surgeon I remember taking the Hippocratic Oath as a right of passage however the true meaning of this simple saying never really hit home until my chief year of residency. In order to “First do no harm," one must have the medical education to make the correct decisions and treat within their own capacity. We live in a country and medical system that focuses on patient care, patient satisfaction, resident education, and excellence in medical treatment and therefore we are surrounded by arguably the best medical and surgical care. We often take that for granted. Traveling to Tanzania brought everything into perspective for me and I quickly realized that there is a vast need for international medical education and charitable outreach.


Being raised in a first generation American household, I was always raised with cultural acceptance. After traveling to various international locations, I have expanded my personal interest to pursue international medicine and make that part of my future surgical practice. The opportunity given to me during my chief year of residency, to travel internationally for an elective surgical experience, was one I was looking forward to for the last 4 years. After searching for the appropriate experience, I found the SIGN (Surgical Implant Generation Network) program at the Muhimbili Orthopedic Institute (MOI) in Dar Es Salaam, Tanzania. While preparing for my trip, I don’t think I realized the eye opening experience I was about to have.


When I first arrived in Dar Es Salaam, I was shocked to see the size of MOI. As one of the largest Orthopedic providers in eastern Africa, the hospital has to be large enough to accept patients from near and far. One of the most apparent differences to me when I first arrived was the overwhelming need for trauma care. A new word I learned when in Tanzania, “piki-piki”, was used to describe the relatively cheap motorcycles that were found on every street. Locals did not always have driver’s licenses or the safety equipment we are used to, and this led to a large portion of the blunt trauma injuries that we saw. I still remember my first call Saturday (referred to as “surgical camp”), as we ran multiple ORs staffing femur fractures all day long. I myself was in one room while others residents were in other rooms.

Through the implementation of the SIGN nail, which allows for intramedullary fixation of long bone fractures without the use of fluoroscopy, the treatment for femur fractures at MOI has changed over the last few years. As resources are limited, they have focused on the treatment of these patients and have improved their efficiency and outcomes considerably. Patients with femur fractures are now taken to the OR the day they arrive and are usually discharged on POD #1. This lessens the overall burden on the hospital and allows other patients to use the limited bed space and facilities.


Another eye-opener was the state of the patient wards and the care provided before and after surgery. My first visit to the patient wards was shocking to say the least. Within the public ward (for a majority of patients who lack private health insurance), large rooms are lined with cots full of patients and overflow patients lining the floors and hallways. These patients have family members to help prepare meals and care for them during their hospital stay. After meeting these patients and experiencing their gratefulness, even in the face of such hardship, I truly felt the impact of our contribution from both a surgical as well as educational standpoint.



At MOI, I worked with not only the faculty, but also with residents in training.  Over their various levels of training, there was one trait that was common, the desire to learn more.  I was constantly asked for more orthopedic resources and was able to share with them some of the Wash U educational curriculum.  I was given the opportunity to give a lecture and afterwards, the director of orthopedics approached me to let me know that the most important principle I taught was how to analyze the literature and practice evidence based medicine.  Once again, I realized that we take for granted our education system and have so much that we can offer when it comes to the developing world.

As in most of the developing world, limited resources in Tanzania restrict much of orthopedics to trauma and tumor cases.  It is with the advent of devices such as the SIGN nail that time and resources can be used for other types of orthopedic cases.  That being said, trauma is still the vast majority of care that is provided in this setting.  However, even though they are strapped for resources, I quickly learned that amazing care could be provided when there is the will to help and the will to learn.  One of the hardest things to deal with in the developing world is that you have to handle cases with what equipment and technology is available.   That being said, it’s amazing what can be done with limited resources.  I witnessed innovative surgical styles and treatment options for difficult problems during my time at MOI and hope to use that innovative style in my future career.  More importantly, I met surgeons at MOI that are training the second generation of well trained orthopedic surgeons in Tanzania, and I was proud to be a part of that effort and hope to continue with this in the future.

Cambodia

By: Maggie Kuhn, MD

Medicine does not exist in a vacuum. It’s a simple enough concept, and statement for that matter. There are probably hundreds of essays written with this premise every year, by college students eager for medical school acceptance. And how we practice medicine is reflective of our priorities: not only as physicians, but as a society and a culture. I know that I understood this at one time, and I know that I even contemplated in the past. But life gets busy: we get up early, we round early, we see patients and put out fires and attend conference all before a 7:30 am start. We go, go, go, we complain that anesthesia is slow, that the nurses are slow, that the patients aren’t compliant, that the other services don’t really care—and before we know it, we’ve been at this five years.

This experience for me, going somewhere completely foreign and seeing medicine in a completely new context, has been one that has required me to slow down. And slowing down, for me, has proven immensely difficult. Kossimak Hospital has an 80 bed orthopedic trauma unit. But things at Kossimak are different now than they were 2 years ago. Two years ago, the 80 beds were filled—so much so that two visiting surgeons contributed over £150,000 to build a new unit. But two years ago the government changed the compensation structure for surgeons and hospitals. For reasons unclear to me, prices for patient care went up and physician compensation went down. Now, the ward is at least half empty—patients cannot afford the $280 surgery fee, or the $30 a day to stay in the hospital. Most of them go to traditional healers or ‘bonesetters’ for their initial care. Otherwise, they go to the less expensive and closer provincial hospitals. This poses two problems. First, their care is not as good: resources are even more limited and physicians are less trained. Secondly, appropriate care is delayed—when the patients finally do present, it is months or years later, and fractures have become nonunions or, worse, malunions, elbows are stiff, joints are contracted, and the patients have lost their jobs.

Despite this, the dedicated surgeons at Kossimak continue to operate as much as they can. Four of the five operating rooms on the campus are dedicated orthopedic rooms, treating almost exclusively trauma patients. The crowdedness of city streets, the prominence of “motos” or scooters, and the lack of traffic laws (or, at least, their enforcement) make for plenty of business. The surgeons at Kossimack, and especially their dedicated chief of staff, Dr. Bunn, have done more SIGN nails than any other institution worldwide: over 1,300. The nail itself allows for long bone fractures, which are by far the most common orthopedic injuries seen in Cambodia, to be treated with intramedullary fixation. In the US, this fixation technique is frequently utilized in order to stabilize fractures internally and to allow patients to ambulate early after surgery. The alternative is the time tested and reliable “traction” technique, whereby patients with lower extremity fractures are maintained in bed, with traction applied to the affected extremity, until they heal—often upwards of 8 weeks.

Conditions in the operating rooms are sparse. There is air conditioning, but no running water in the rooms. Drapes are cloth and, often, rattled with holes that require multiple adjustments to maintain a sterile field. The surgical trays are sparse: one drill, but otherwise without power tools. There is one needle-driver and one knife blade per set, and generally very little uniformity to the trays themselves. All bone reaming and screw placement is done by hand, and all screws have to be hand tapped. Probably the most glaring difference with respect to the operating room setup is the fact that fluoroscopy is notably absent from nearly all procedures. Of all the frustrations I encountered trying to acclimate to a different system of operating and of administering health care, this was likely them frustrating. Lack of fluoroscopy, or intraoperative x-rays, is not uncommon in the developing world. In fact, the SIGN nail was developed expressedly to avoid the need for fluorography in the OR. But Kossimack hospital has two fluoroscopic machines, one in each of 2 operating rooms, which have been donated. Despite having the machines, the surgeons are exceedingly reluctant to use it, as many believe its use will make them impotent.

It is the care before and after surgery, however, that was most disparate from my own experience. If you were to sustain a femur fracture in Cambodia, say from a moto accident, your family would drive you to the hospital—in a car if you had one, but more likely on the back of a moto or a bicycle. If you had insurance, you could stay in the air conditioned rooms, but if not, if you’re like most Cambodians, you would be escorted to a room with 8 beds, a fan and no linens. For $30 a day, you could stay in the hospital and be provided IV drips, medications and dressings for your wounds. Your family would have to pay this daily fee on a daily basis—actually to the physicians themselves. Food and water, of course, are not covered, and families provide these for patients. Similarly, while nursing care is available for dressing changes and medication administration, family members bear the burden of moving patients to and from bed, changing bed pans and getting the patients up on their feet and beginning basic physical therapy. Not food, of course.. If you needed surgery and could afford the $280 surgical cost in addition to the cost of the implant used, your surgery would be scheduled two or three days after your admission. Your chance of contracting a post-operative wound infection would probably approach 10% if you were young and healthy, and your hospital stay would be about 5 to 7 days (or, as many days at you could pay for.) While these costs seem dramatically low, they are relatively high for Cambodian citizens, many of whom make less than $1,000 annually. Surgical orthopedic care is prohibitively expensive, and many patients simply cannot afford to come to the hospital, at least not initially.

The concept of outpatient care, both pre and post-operatively is a relatively new one at Kossimack. The surgeons there, with the help of World Orthopedic Concern, have recently established an outpatient clinic where patients can be seen. The concept, however, has not yet caught on with patients, many of whom have difficulties returning to the hospital due to lack of transport or job/family requirements during the day.

There are a host of things that I’ve taken away from this experience that I found profound, particularly as I reflect upon them having returned to my comfortable, efficient, wealthy hospital. The first is that it’s very difficult for me, as a surgeon, as one trained to be productive and to fix problems, to work in an environment in which efficiency is not optimized. I found myself, in Cambodia, constantly looking for the next case, trying to find more to do. The pathology is plentiful, but the resources and infrastructure are not: both on the patient side and on that of the hospital. The reality of this, however, was that I had to slow down and observe, think, talk to people and try to get the slightest sense of what it means to be Cambodian. More so even that operating, my favorite part of the day was board rounds with the staff surgeons, residents and medical students, the time each morning when we all gathered to review the week’s cases and discuss treatment plans. This was the time of day when I was most aware of just how much these well trained surgeons are forced to make medical decisions based on non-medical considerations: patients who cannot afford surgery with distal radius fractures get percutaneous fixation under regional anesthesia, patients who I would recommend for operative fixation with plates receive ex-fixes because no plates are available, anywhere in the country. It becomes difficult to define “standard of care”—that standard is so dependent, on patient finances and resource availability.

In the five years since I became a physician, I have, for the most part, stopped noticing just how profoundly our culture is intertwined with the way we practice medicine. The American medical infrastructure is enormous: it is legislative, administrative, medical, financial, intellectual, judicial and even religious. But what would medicine be if there were no government, no legal system, no money, no laws, no religion, no family? And how would you practice it outside of these entities?

When Pol Pot’s regime crushed Cambodia, it crushed not only a people, but an entire infrastructure. And now, thirty years later, the surgeons at Kossimak Hospital are desperately trying to practice medicine with an infantile infrastructure. There are patients, and there is pathology everywhere, and there are physicians who want to fight it. And in this situation, particularly as a surgeon, it is tempting to start formulating a plan—figuring out how we, as Americans or as western surgeons, can show these people how to succeed. But that is a delicate and dangerous thing. It is tempting to see the world in black and white, with good or bad fixation, with good or bad results—but this experience is teaching me that even those are relative.

Blantyre, Malawi

By: Corey Gill, MD

Malawi is a landlocked country in sub-Saharan Africa. It is known as the "Warm Heart of Africa" and I have certainly felt this to be the case in my 3 visits to the country since 2002. Before writing about my recent remarkable chief resident experience at an orthopedic hospital in central Malawi, I would first like to briefly mention some aspects of Malawian culture and the unique travel experiences I have participated in during my visits there. Malawi is a former British colony that gained its independence in 1964. The largest ethnic group is the Chewa, and the predominant local language is Chichewa. The primary source of food in Malawi is corn, which is milled and then cooked into a product called nsima. Nsima looks and tastes similar to the grits I grew up with in the Southern United States, and is eaten at virtually every meal. Malawi is partially bordered by the large and appropriately named Lake Malawi. The lake is home to 80% of the aquarium fish in the world (cichlids), and there are a number of beautiful towns to visit along the lake's borders. There are a number of great national parks in Malawi and neighboring countries where one can see wildlife such as elephants, hippos, and lions. Malawi is located along the Eastern Rift Valley, with mountains and dramatic elevation changes seen between the northern and southern ends of the country. This geography is great for activities such as mountain biking. I was fortunate to participate in a 70 km off-road biking day trip with one of the head orthopedic surgeons on my recent trip there.

Despite its cultural riches, Malawi is one of the poorest countries in the world, with few natural resources and a life expectancy of approximately forty. There are 6 orthopedic surgeons in the country serving a population of 15 million people. In contrast, there are approximately 1000 orthopedic surgeons in the United States serving 15 million people. For my international rotation, I travelled to the BEIT Trust CURE international pediatric orthopedic hospital in Malawi's largest city, Blantyre. This charity-run hospital is staffed by 4 pediatric orthopedic surgeons who perform over 1000 procedures each year on Malawian children with a variety of conditions including: angular limb deformities, chronic osteomyelitis, untreated clubfoot, metabolic bone diseases, burn contractures, and orthopedic tumors.

The difference in care of orthopedic conditions in children in Malawi and the United States is dramatic. Fractures, such as supracondylar humerus fractures, are rarely treated surgically for a variety of reasons. There is not enough manpower to perform the surgeries, orthopedic implants are very limited in supply, and children often don't present to the hospital for weeks to months after their injuries. For example, shortly before I returned home, I saw a 14 year old child who fell out of a mango tree one year prior to presentation and complained of pain with walking. X-rays revealed an obvious displaced femoral neck fracture, a condition that would have prompted a trip to the emergency room shorty after injury 100% of the time in almost any city in the United States. For many of the conditions that I saw during my visit, presentation to the hospital occurred much later in the disease process than in developed countries. Children with osteomyelitis often had major sequelae of their infection such as large areas of involved bone requiring resection, children with clubfeet were often untreated as infants (although this is beginning to change significantly after institution of a nationwide nonoperative treatment program using the Ponseti method), and children with orthopedic tumors often did not present to the hospital until a large soft tissue had been present for many months.
Despite the severity of conditions seen in many children, the orthopedic surgeons and nurses that I worked with were often able to cause dramatic changes in the lives of the children and families seen at the hospital. Because their conditions were often severe with significant associated morbidities, surgeries that even partially improved or corrected various orthopedic pathologies dramatically improved the quality of life of these children. In addition, there is a large amount of stigma associated with orthopedic diseases in Malawi such as angular limb deformities, polydactyly, or joint contractures secondary to infection. Children with these conditions are often seen as cursed or bewitched by other members of their community and ostracized by the villages they live in. Educating parents that their children are not cursed gives them comfort and relief, and improving their childrens' cosmetic deformities better enables them to reintegrate into their communities in addition to improving their clinical function.
I was amazed during my visit at the level of stoicism, maturity and gratitude displayed by young children treated with major surgeries. For example, we performed an above-the-knee amputation on a 10 year old girl with an osteosarcoma (malignant bone tumor) of the distal femur. Despite receiving only Tylenol for pain, she was thanking us on post-operative day #1 for taking care of her and walking around on crutches with a big smile on her face. Another child with an unknown metabolic bone disease being treated with a Taylor spatial frame for a failed attempted knee fusion sustained a fracture of his femur above one of the pis from his frame. The orthopedic surgeon who performed his most recent surgery told the patient he was sorry that he was having to go through with so much, and the patient replied by trying to comfort us. He said, "Don't worry, everything will be OK."
In addition to my time at the pediatric orthopedic hospital, I spent some time at the adult hospital across the street. Surgical orthopedic care of adults at this hospital is minimal, even when surgeries are indicated. OR time is sparse, anesthesia care is suboptimal, stores of orthopedic implants are minimal (the day before I left, one of the orthopedic surgeons had to tell a patient with a Galeazzi fracture dislocation that surgery could not be performed because there were no plates in the hospital at that time), and patient triage is difficult (patients often sit in the hospital for weeks with a fracture before an orthopedic surgeon is told about them). In the face of these multiple difficulties, the one dedicated adult orthopedic surgeon in the country does remarkable work caring for the patients he is able to, but the situation is certainly appalling. I asked one of the orthopedic surgeons I worked with what happens to people with significant orthopedic injuries like open fractures from road traffic accidents (a common problem in Malawi) that need orthopedic intervention. He replied candidly "If they are lucky, they die at the scene."
While improving orthopedic care in developing countries is faced with difficulties at multiple levels such as appropriate triage of patients, remarkably insufficient number of surgeons, and gross inadequacies in healthcare infrastructure, I do not think this provides an excuse for apathy or maintaining the status quo. While we as residents are generally not able to dramatically impact patient care during our relatively short visits to places like Malawi, Mongolia, or Nicaragua, we certainly come away from these experiences with a new perspective and appreciation for the types of care available in the United States. These experiences highlight for us the need for resources, manpower, education, and infrastructure to improve orthopedic care in developing countries and hopefully will make us more likely to participate directly in this improvement during the course of our careers. In the short-term, we can educate other orthopedic surgeons and the community as a whole to the need for awareness and monetary donations to organizations like CURE internation (www.cure.org) or SIGN (www.sign-post.org) that are actively improving the care of thousands of pediatric and adult patients in developing countries around the world.