Thursday, October 4, 2012

Antigua, Guatemala

By: Muyibat Adelani, MD

Operation Walk is a nonprofit medical volunteer organization that provides free surgical treatment for arthritis in developing countries. It was founded by Lawrence Dorr in Los Angeles in 1995, and now there are eleven teams from various regions in the United States who conduct yearly missions to perform total hip and knee replacements for those around the world in need.

I traveled to Antigua, Guatemala with the Operation Walk Virginia team. Based out of Alexandria, Virginia, this team was founded by Gerard Engh in 2006. It consisted of orthopaedic surgeons, anesthesiologists, operating room staff, internists, nurses, and physical therapists, all of whom were dedicated to not only performing the surgeries, but also pre- and post-operative teaching and patient care.

Day 1: As soon as we arrived in Guatemala, we went to the hospital, Las Obras Sociales Hospital, where we would be working for the week, in order to meet the staff and tour the facilities. This hospital is the only hospital in Guatemala where joint replacement is performed. The waiting list is 500 patients long. This hospital serves to host multiple mission groups in all specialties; they host 36 trips per year. The staff there is present to offer whatever support they can to these groups.

Day 2: The entire group went to the hospital bright and early to begin screening the patients. We divided into four teams, which each saw about fifteen potential surgical candidates. Most were elderly, some were young. Some had complex deformities. Some had complex medical conditions. When it was over, we met up together to discuss each patient and to determine who would be the best operative candidates. That afternoon, we operated on four patients.

Day 3: This was the first big OR day. We had four rooms running simultaneously. Each room had two surgeons and a surgical assistant (or me). In total, we did 12 patients. I did a total hip replacement in a 34-year-old man with a childhood hip disorder. That night, there was a big dinner for the entire Operation Walk team at a very fancy Argentinian steakhouse.

Day 4: Another big OR day. In four rooms, we were able to do 16 patients. I got to work with Dr. Gerard Engh, the surgeon leader of the team. We did four knee replacements together that day.

Day 5: This was the last day in the OR. We did 12 patients that day. In total, we did 54 joints in 44 patients. Six were hip replacements, and the rest were knee replacements. We also did a total knee removal, or explant, for a patient who had a knee replacement by a previous Operation Walk team, and has subsequently developed an infection.

Day 6: Everyone returned to the hospital to help take care of patients on the floor. We all passed medications, changed dressings, and walked with our patients. It was very rewarding to see how well our patients were doing so soon after their surgeries. We also had a postoperative x-ray conference, which gave us all a chance to see the results of our surgeries.

Day 7: The last day. Again, we all returned to see our patients. And then it was time to say goodbye. We took photos with the patients. We did final discharge planning. Then, it was time to return home.

I am very grateful to Dr. Engh and the rest of the Operation Walk team for the opportunity to join them on their trip!

Wednesday, September 5, 2012


By: Greg Nelson

Why my interest in Zimbabwe? Each year, one hundred graduate and professional students in America are invited to the International Achievement Summit. A networking event for the next generation’s movers and shakers, this conference brings the young talent in politics, medicine, law, and the sciences face-to-face with a “Who’s Who” of prominent professionals in every sector, from music and entertainment to politics and literature. Although I had dinner with Sam Donaldson and heard an inspirational speech from the then Junior Senator from Illinois, now President, Barack Obama, the most influential conversation I had was with another attendee.

He had recently returned from medical service in Southern Africa and shared about the devastating effect of “the medical brain drain”. Simply put, the best and brightest students in developing nations realize that either they cannot be adequately trained in their home country or their nation of origin cannot support their future medical practice, so they travel to the West for training. Once they are licensed physicians, they stay abroad and send money home. This however, prevents their countries from developing the necessary intellectual and professional capital to expand capacity and deliver appropriate care to its citizens. A vicious cycle ensues. Through our conversation, it became clear that education and infrastructure are the two most critical components to breaking this cycle.

After making a fortuitous contact with a Zimbabwean Church Pastor, Mbonisi Malaba, the vision for this trip quickly fell into place. I shared with Pastor Malaba that Washington University School of Medicine sponsors its chief residents for an international trip that would allow me exposure to Orthopedics in a developing context. Personally, I wanted to identify a hospital that was training or wanted to begin training native students to become native orthopedic surgeons and serve the population around them. In addition, I desired to develop a long-term relationship that would allow me the opportunity to contribute not just to patient care, but to education, so that by “teaching them to fish”, they might “eat for a lifetime”. That’s how Zimbabwe became the perfect location for my trip.

On my first morning in Bulawayo, Zimbabwe, I finally met Dr. Msasanure in person for the first time. What kind and gracious people Zimbabweans are! Dr. Msasanure picked me up and I joined him as he rounded on patients first at his private clinic and also at the private hospital. We then traveled to my main site, the United Bulawayo Central Hospital (UBH). The hospital matched many of my expectations. First off, the staff is very friendly. As for the exterior, it's not bad, actually. The inisde was a different story. I wouldn't describe it as run-down, but it is clear there haven't been any renovations since it was built. The ORs are surprisingly similar to the US. The anesthesia machines in the ORs are relatively new but the Anesthesia team is still the source of most operative delays. I have to give them a break though, since there is no Anesthesia attending, only junior residents and interns running the anesthesia.  

As for the operative case load, patients generally present with their broken bones relatively late compared to the U.S. Even if they show up the first or second day, there is a wait for all but the most urgent problems due to a lack of either Anesthesia, Surgeon, or equipment availability. And, there is a queue of patients already waiting (up to 8 weeks) for their surgery. Even open (a.k.a. compound) fractures were not usually treated with emergency surgery, as we would do in the U.S. There are a lot of road traffic accidents in Zimbabwe and open tibia (shin bone) injuries are common. These patients are preferably treated with an external fixator, but due to a shortage of implants, these patients sometimes undergo surgery to clean out their wounds and try to prevent infection and then go into a cast. This patient actually received an external fixator because she was able to afford to buy one.
One memorable patient was a 5 year old girl who, by my best reasoning, must have suffered an open fracture of her arm just above the elbow but did not have adequate treatment (operative irrigation and debridement). Then she presented with about a year's worth of swelling and pain that developed into a draining wound. By the time she got to surgery, she had dead and infected bone sticking out of the skin. Not a pretty picture. This proved to be a more difficult problem than I anticipated. We made our incision and within 20 minutes I pulled out of her arm what probably had been the (dead) lower 1/3 of her humerus bone (save the elbow joint). Everything else in there was new bone her body had formed to heal the fracture and try to wall off the infection. We then inadvertently re-broke her fracture, which would have probably been inevitable, but in this case was fortuitous because it gave us better access to the infection. After scooping puss out for another 30 minutes or so, I got some practice using K-Wires to fix the fracture. We then closed the wound and put her in a splint. All in all, a quite satisfying procedure (assuming her arm heals), since she certainly wasn't going to get better on her own. I also enjoyed being given so much autonomy when 1) I am a visitor here and 2) we don't see a lot of this in the U.S. It felt like a win for the patient as well as for me.

Our final surgery was also noteworthy. This patient was a police officer who had been sent to investigate a death in one of the villages. He and his partner had to exhume the remains of a tribe member but the tribal chief didn't like this and gave them some grief about it. After the autopsy, they were returning the body to the village and suffered a roll-over car accident in which the coffin fractured his right thigh bone (femur) and nearly severed his leg. Needless to say he had emergency surgery and a nail was down the center of the femur to fix his injury. Well, sadly, he started walking on his new leg and the rod bent. Now he has a crooked leg and a bone that didn't heal. Our problem was that we couldn't remove the rod by pulling it out (since it was bent) and the team here had already tried to straighten the nail (that didn't work), so we opened the fracture site and found the nail. We tried to cut it with bolt cutters, but the nail was pretty thick. We managed to crimp the nail substantially, and then we commenced to bend the femur (and nail) back and forth until it broke. We have some excellent photos of this and a little video somewhere to commemorate the brute strength of American Orthopods in UBH. Anyway, we removed the two bit of nail and put a fresh rod in its place. We found some infection and dead bone at the site and made sure to treat that while we were there. Needless to say, another procedure we don't do much in the U.S.

Tuesday morning we had team rounds. The rounds are performed in a manner much more similar to that of the medical services rather than surgical services in the U.S. Simply put, we walked to each patient's bedside, reviewed their case, and using the Socratic method, Dr. Msasanure taught about important aspects of the care of each patient. The hospital wards are similar to those I’ve seen in pictures of other residents’ trips. Large rooms lined with beds and little privacy. There is no heat and not AC, but at least there is nursing care here. Many developing nations’ hospitals require family members to perform nursing care (feeding, bathing, changing bandages, etc). Later in the week I joined Dr. Sawene, one of the junior housestaff for Orthopedic rounds. Sawene, a tall, lean native Zimbabwean, is probably the equivalent of a PGY-2 resident in my program. That means, as a PGY-5, I was the senior member of the Orthopedic team. So, as we rounded, I pointed out important aspects of the care of each patient, trying to add unique factoids that had not been addressed in the previous day's rounds. I don't know if the team was just especially considerate since I was a guest, but they were quietly listening and I felt like I actually had something meaningful to contribute.

After rounding, we sat down for the interspecialty afternoon conference. I had the pleasure of giving this lecture. Luckily, I had "prepared" (read: borrowed) a couple of lectures from other residents right before I left for Zim. We discussed mid- and hindfoot trauma and I think it went well. The two Orthopods seemed to enjoy hearing about these uncommon, but serious foot injuries. Interestingly, the young general surgery attending who gave the AM conference was the most involved, but as a trauma surgeon, he was well versed in the orthopedic trauma assessment.

Thursday mornings began with the outpatient clinic at UBH. Once again, this is the public orthopedic clinic for patients without insurance who cannot afford private care. Of course, that means that the resources are limited. In fact, we saw about 50 patients in 3 hours. Most of the patients had typical orthopedic problems that, while being treated differently being that they were in Zimbabwe, were having great outcomes. It was very eye-opening, but still fun. I especially enjoyed discussing the differences in treatment approaches in the US and Zimbabwe, and trying to learn to think like a Zim Orthopod and come up with solutions that require less surgery and less metal.

The UBH club foot clinic, started in 2010 by Dr. Malango, was actually one of the brightest spots in my international experience. The foundation of modern clubfoot care is a (mostly) nonoperative approach to treating these deformities. The beauty of this is that, not only does the Ponseti method give better results than classic surgical intervention, it can be practiced anywhere there is plaster. So, Dr. Malango and a team of nurses at UBH have attended some training sessions put on by one of the CURE International Hospitals (in Uganda) and are now providing this care to Zimbabweans. In fact, the proof of the success of this clinic is that many patients are being referred to them from other hospitals and surgeons (often after failing operative treatment). Our very own Dr. Matt Dobbs at Washington University is probably thinking to himself, "That's absolutely right, Greg. Clubfoot treatment is fascinating. No two are quite alike"

The clinic has a couple of really amazing success stories too. There is a 12 year old that they have treated with a series of 50 casts and intermittent stretching and have corrected his feet to nearly normal, even though he had failed the old surgical treatment before he started his casts. Personally, I find this to be very exciting because this is clearly an area of orthopedic care that can easily be exported to neighboring regions with minimal economic burden to an already fragile health care system. After discussing their experience with the Ponseti method, I assisted the nurses in putting on a few casts. I realize I actually learned something from watching Dr. Dobbs put on, like 100 casts, as a 2nd year resident. We then did a couple of percutaneous tenotomies.

All in all, I believe my time in Bulawayo was more transformative for me than for any of the Zimbabweans. And, that’s how it should be. I didn’t expect to do anything amazing in my two weeks, except potentially learn from these amazingly resourceful and compassionate physicians. Hopefully, I can find some small ways to continue to contribute to their efforts to improve their delivery of care and their training process. And, if I’m lucky, one day soon I’ll return to Zimbabwe for another experience. Perhaps, this is the beginning of a mutually beneficial partnership.

Wednesday, February 29, 2012

Lima, Peru

By:  Jim Ross, MD

Secret of the Andes, by Ann Nolan Clark, was a book that I stumbled upon as a child. It is a story of cultural mystery and personal identity. The main character is a modern-day Native American boy who along with his guardian tend a herd of prized llamas in an isolated valley in the Andes Mountains in Peru. The boy is unaware that he is a direct descendant of the ruler of the ancient Incas. Throughout the book, he is instructed by his guardian in the religion and history of his ancient people, and goes in search of his true identity. Growing up in Minnesota I was fascinated to learn of a different type of culture such as was presented in this book. The descriptions of the culture, nature, and history were fascinating to me. I had visited my girlfriend’s family in Peru prior to this opportunity, but had little interaction with the health care system nor understood the difficulties of treating patients in this poverty–stricken environment. I have always had an interest in over-seas volunteer work, and have always wanted to create contacts in order to volunteer on an annual basis. This was the perfect opportunity for me to visit one of the hospitals in Peru, establish contacts so that I can continue to assist the health care and also provide education to the Orthopaedic department.

Dr. Gaston Barnechea is an Orthopaedic Surgeon who is also the contact for the Nacional Guillermo Almenara Irigoyen Hospital (Almenara Hospital). He assists in coordinating volunteers as well as Project Walk, which is an established program that provides joint arthroplasties for those in need. The Almenara Hospital is part of the El Salud Health System, which opened its doors in 1941. It is located in La Victoria, which is one of the 43 different districts that are a part of the city of Lima contributing to a population of over 7 million people. It was originally envisioned to become the center of Lima, as a commercial and industrial empire, with the largest textile industry in Lima in addition to several stores, shopping centers, and workshops. However this area has become partially overrun by the highest crime rates in Lima in addition to a “recycling” center in which garbage is essential dumped on the various streets and is rummaged by the people in the area. The hospital is also near the medical school, the University of San Marcos, as well as the training facility and stadium for the Club Alianza Lima, which is the Peruvian first division soccer club that is the one of the most famous and well-supported clubs in the country and the oldest teams in the Peru.

The hospital currently has approximately 1,000 inpatient beds however has many overflow areas. There is also a very busy emergency room as well as an ambulatory day surgery center with 14 operating rooms. The inpatient wards are organized around a nursing station, and each ward is dedicated to a specific specialty. Orthopedics/Traumatology has one ward which houses nearly 100 patients. However, given that the Orthopaedics ward is always at maximum capacity, patients are also scattered amongst the other wards. The Orthopaedic/Traumatology service is divided into 2 separate teams. The team that I joined was one that dealt mainly with trauma and joint reconstructions. The other consists of surgeons that specialize in spine and hand surgery. Within each team, there are approximately six surgeons who are assigned different shifts. The operative days are divided into a morning shift, which runs from about 8:00 am to 2:00 pm and an afternoon shift, which runs from 2:00 pm to 8:00 pm. Each team is given one room, and within that room 2 of the staff members operate together. Each team is also assigned 2 residents, who in addition to taking care of the inpatients at Almenara Hospital spend time in other hospitals in the area. They usually take turns scrubbing for the cases. The residency program is 3 years in duration and is spread out amongst various hospitals throughout Lima. In total, there are on average 30 residents in Lima, 4 of whom are at Almenara Hospital at a given time. There are no formal lectures or education and thus the residents and staff were always eager to learn.

After my first trip to the hospital, I instantly realized why the hospital sees the vast array of trauma. There are essentially no stop signs or traffic lights at the intersections, and each car is fighting for its space in the street. Amongst the many cars, there are also many people riding scooters, motorcycles, and “moto-taxis” which is essentially a dirt bike with a carriage attached to the back. All of these vehicles are in addition to the many people who are walking across the streets or standing in the center of intersections selling various items and food. Taxis are very inexpensive as a trip to return to my hotel which was approximately a 20-minute ride was usually 15 nuevo sol (~$6) and would fluctuate depending on my bargaining skills.

The typical week started on Monday with an indications conference. The residents would present all of the current inpatients and new patients that were admitted over the weekend and treatment would be discussed amongst the staff. Given that a majority of the implants are not within the hospital, treatment would be decided and the implant companies would be contacted. One of the difficulties, however, is that implants such as femoral nails or proximal tibial locking plates usually takes well over a week to be delivered to the hospital. A vast majority of the fractures are treated at 3 to 4 weeks in addition to many nonunions and pseudoarthroses that are years old. It was very humbling to realize how lucky we are to have all the various instruments at our immediate dispense.

My Monday afternoons, in addition to the remaining week days would all consist scrubbing in all the cases. There were a vast array of fractures including multiple tibial plateau, ankle, hip, long bone, and pelvic fractures. There was a gunshot to the proximal tibia, which the staff found very interesting as they see about 3 to 5 fractures sustained from gunshots per year. They were astonished when I mentioned that our trauma service sees that amount usually within 2 weeks. The highlight of my operative experience was teaching the staff various techniques that they had not used and teaching the residents simple techniques such as interfragmentary lag screws and reduction techniques. I was also fortunate to show the staff percutaneous sacroiliac screw fixation. This had to be planned well in advance, as there is only 1 fluoroscopy machine for the entire operating rooms, so more than 90 percent of the cases were done without fluoroscopy. Intra-operative decision-making is also very different in that one has to be quite creative given the limited availability of supplies.

Given that many patients have delayed operative fixation of their fractures, it is not uncommon for external fixators to be placed in the emergency room. There is a procedure room in the ER where small cases are performed, including ex-fix applications. Some of the patients that have ex-fix’s placed end up having this as their definitive treatment if their wait for surgery is long enough. Despite being a hospital with limited resources, it is still difficult for a patient to be admitted. The patients that are allowed admission are those that have priviledges similar to the U.S. Medicare/Medicaid system. Spanish serves as the primary language amongst the patients and the staff. The staff knows little, if any English, which put my Spanish to the test and made some discussions difficult especially since medical language is different in itself.

The weather in January, which is considered the beginning of summer, was consistently in the 80’s with lots of sun, few clouds, and only occasional rain at night. The country prides itself on Peruvian cuisine, which I agree is the best food I have ever eaten in my life. Ceviche is a staple that is prepared with uncooked fish or other marine life that is marinated in fresh lime juice and aji amarillo (a salsa of spicy yellow pepper). My other favorites included anticuchos (grilled beef heart), lomo saltado, conchitas a la parmesana, causa, and of course Cusquena and Pilsen (Peruian beers). The also tasted fruits that I have never seen or heard of before, and all the fruits that are found in the United States were much better there. I was also very fortunate to have an additional week to travel with my girlfriend and her family, experiencing the culture and various scenic areas that the country offers.

Overall, the patients have immense gratitude to the physicians, quite frankly more than I have ever witnessed before. They are constantly thanking the physicians and family members will seek out the physicians to thank them for their caring for their family members. It is quite remarkable and humbling, and I cannot wait to visit again. Viva Peru!!

Monday, January 9, 2012

Coimbatore India

By: C. Tate Hepper, MD

As a child, my twin brother and I used to joke we were going to dig our way straight through the center of the globe to India, or the other side of the world. This December I traveled there. Long flights are certainly not my idea of pleasure. However, the opportunity to travel halfway around the globe to Coimbatore, India and visit a world-renowned plastic hand surgeon was something I could not ignore. The additional opportunity to participate in a week long microsurgery course sweetened the deal to deliciousness.

Dr. Raja Sabapathy, a master surgeon, hospital administrator, and researcher, is the Director and Head of Plastic Surgery at Ganga Hospital, a 400-bed orthopedic and plastic surgery specialty hospital founded by his father. Ganga is located in the heart of Coimbatore, the “Manchester of South India”, so named for its bustling textile industry. Coimbatore is a tropical town of just over 2 million people in the southern province of Tamil Nadu. The weather in December, the heart of “winter”, was pleasant with high’s in the mid-80’s. Poverty is widespread. Rice is the staple food.

I quickly realized that India is an extremely diverse country with a multitude of languages and cultures. Trainees in Ganga Hospital hail from all areas of India, and therefore, speak different languages and dialects. Much to my delight, English serves as the common language of everyday communication in the hospital. English is also widely spoken in the community, although I still found it difficult to communicate. The people both in the hospital and in the community were astoundingly pleasant, warm and friendly.

The plastic surgery service at Ganga mainly treats traumatic extremity injuries, but they also have a vibrant diabetic foot clinic. The volume of trauma is astounding. Most of them come directly from Coimbatore but there are also patients seeking Dr. Sabapathy’s expertise who travel from around the country and internationally.

The volume of trauma doesn’t come as that much of a surprise after you spend a few minutes on the streets. The flow of traffic resembles a whitewater river consisting of hundreds of people riding two-wheelers (motorcycles and scooters) sans helmet and shoes intermixed with “autos”, small cars, trucks and overcrowded large buses. Many two-wheelers will have multiple riders clinging on. I saw a family of five with groceries on a single motorcycle! The “autos” are motorized open rickshaws powered by a very small engine that serve as taxis. A trip across town runs 100 rupees (~$2). Traffic laws, if they exist, are not obeyed. Industrial machines and farming equipment provide another steady supply of mangled extremities.

My first week was spent observing in clinics, operating theaters, and the physiotherapy department. I was joined by several other trainees from around the world. Also visiting were a Russian hand surgeon, a British plastic surgeon, a plastic surgeon trainee from Mumbai, and three hand surgery fellows from Hyderabad. There was much lively discussion and debate on appropriate management of certain patients.

The culture in India frowns deeply upon amputation. Therefore, nearly every mangled extremity is salvaged. Severe injuries that would not be salvaged in the States are reconstructed with multiple surgeries and physiotherapy. Common cases include debridement of acute injuries, replantation, soft tissue coverage, and reconstructive surgeries. There were 10 free flaps performed my first week! Devastating mangled extremities are routine and are therefore approached in a systematic manner. Nearly every fracture is treated with an external fixator or simple Kirschner wires.

Neuropathic diabetic foot ulcers are treated aggressively with soft tissue coverage including free tissue transfer. They also treat a large volume of patients with brachial plexus injuries with a combination of osteotomies, nerve grafting, nerve transfers, and tendon transfers depending on the situation. Overall, they have outstanding outcomes.

Anesthesia is critical to the success of any surgical team. Dr. Bhat and his team of anesthesiologists, nurse anesthetists and technicians are amazing. Each patient with an acute traumatic wound is brought directly from the ER to a holding area outside the operating suite. There they are evaluated by the plastic surgery resident and the anesthesiologist. After a quick survey of the injuries, an immediate block is performed. This allows x-rays and further physical exam to be performed without pain.

Once the work-up is complete, the patient is pushed directly into an open operating theater for immediate debridement, stabilization of fractures, and revascularization as needed. I never witnessed a failed block, or a surgeon waiting for appropriate anesthesia. Anesthesia is available around the clock to provide immediate regional anesthesia. Patients are kept awake for surgery. There is often dialogue between the surgeon and patient. The surgeons think it important that the patient witnesses their injury and treatment so they have reasonable post-operative expectations.

India is a country of striking contrast between rich and poor. Never was this more obvious than when standing in the largest operating theater of Ganga Hospital. One can stand near the window and observe a highly skilled team of nurses, anesthesiologists, and surgeons replant multiple digits in an exceedingly efficient, effective manner. Without moving one can glance out the window at the open market that bustles directly in front of the hospital. The market is constructed of discarded scrap metal and cardboard. The roof is strewn with trash and rotting, discarded produce. The aisles are littered with trash, animal feces, and the occasional stray dog looking for scraps. Most people don’t have access to clean drinking water.

Very few people in India have health insurance. Most pay cash for their care, and the level of care is determined by the patients’ means. Those that can afford it are provided a private room with air conditioning, a TV, and a nurse. Those of more meager means are placed in one of several large wards without AC and where family members serve as nursing care. The cost of care is negotiated in advance between Dr. Sabapathy and the patient. There is no pressure to discharge patients in a timely manner, and it is not uncommon for patients to be admitted for weeks or even months.

The second week I spent the majority of my time in the Ganga Microsurgery Training Institute ( The Institute is a state-of-the-art facility with four two-headed Zeiss microscopes and S&T microsurgical instruments. The course has trained over 400 trainees from all over India and 37 countries. The training program has been refined over several years and involves viewing videos by Dr. Aclund and practicing various skills on anesthetized rats under the direction of a seasoned instructor. This was an invaluable experience, which will make the transition to my hand fellowship less stressful and more educational.

Overall, my trip was an enlightening experience. I was exposed to a new culture. I gained an appreciation for the power of a well organized, efficient team of highly skilled clinicians working towards a common goal. I hopefully laid the ground work for a successful future career in microsurgery. I also learned that the only way to travel halfway around the world is in first class. Sitting in coach on a 16-hour flight is almost as bad as digging there.