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.

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