Wednesday, November 23, 2011


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.

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