Thursday, October 4, 2012
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.
Wednesday, September 5, 2012
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.
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
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.
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.
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.
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
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.