Wednesday, May 29, 2013

Managua, Nicaragua

By: Drew Blackman

Prior to my trip to Managua, I had arranged for a hotel shuttle to pick me up at the airport. As I walked through customs and baggage claim, I saw numerous shuttle drivers with whiteboards emblazoned with hotel monograms and guests' names written in dry erase marker. None had my name on it. I continued through the airport and out into the muggy Nicaraguan night. Finally, I saw something name. Written in pencil on a piece of three hole paper ripped from a spiral notebook. I followed the driver, expecting to be led to a bus, or van, or car, or something with the words "Hotel Casa Naranja" on it to reassure me we were heading in the right direction. No such luck. Just a dented, scratched 1990's era Toyota hatchback. I got in and we drove through the night, through unfamiliar boulevards with no street signs. I had studied the city map briefly before my arrival, but as we wound through dark streets past residences made of corrugated sheet metal, I was admittedly lost...and nervous. Eventually, a small lit sign read "Casa Naranja", and I had arrived at my home for the next two weeks while I would experience orthopedic surgery in the capital of the poorest nation in Central America. Hotel transportation was only the beginning of the differences between my experience in Nicaragua and what I am used to in St. Louis.

I spent the majority of my time in Managua working at Hospital Antonio Lenin Fonseca, HALF for short, which is a public hospital that serves as the major referral center for uninsured patients throughout the nation of nearly six million people. In Nicaragua, there are three tiers of healthcare: privately insured, government insured, and uninsured. The gap between three is staggering, but that between those with insurance of any kind and those without is particularly chasmal. The private insurance-only hospitals were on par with most community hospitals in America in terms of resources, facilities and capabilities. The hospitals that accepted both private and government insurance seemed to be on par with smaller American community hospitals. HALF was different. The hospital itself was outdated and the interior lacked the cleanliness one typically associates with hospitals. Patients were housed eight per room, with no air conditioning in the 100 degree heat. Patients, or their families, brought many supplies from home, including sheets and fans. Family members provided much of the nursing care that did not involve administering medications, as well.

The majority of my clinical days spent at HALF were in the operating rooms, assisting primarily in fracture surgeries. Many of the Nicaraguan surgeons who operate at HALF also have a private practice at another hospital to supplement their income, as fulltime HALF surgeons are paid around $1400 per month…although the average income in Nicaragua is only around $2000 annually. On days they operated at HALF, these surgeons would bring most of the necessary equipment with them from their private hospital, including orthopedic implants, instrument trays, patient positioners, and scrub nurses. On days when these outside supplies were not available, the surgeons relied on the hospital’s inventory, which was severely limited. The hospital is unable to purchase many of the newer generation fracture fixation devices that we take for granted in the United States, and thus relies on older fixation devices as well as donations from international surgeons. As a result, options are limited. Issues with outdated sterilization equipment and poor organization within the sterile processing department serve to further limit surgeons’ options at the hospital. Despite all of these challenges, however, the surgeons are able to work with what is available to perform satisfactory operations for their patients. There were six operating rooms, with one or two being devoted to orthopedics per day. Two surgeries per room per day was average, which was hardly enough to keep up with the influx of new patients coming through the doors each night. As a result, on the orthopedic ward, patients with lower extremity fractures lied in bed for weeks, awaiting their turn in the operating room.La Hospital Escuela Antonio Lenin Fonseca, or HEALF, is one of the largest medical training programs in Nicaragua. Their orthopedic residency training programs is regarded as the best in Nicaragua. My trip to Managua was arranged through Health Volunteers Overseas, who has partnered with HEALF to bring international surgeons to HALF with the primary goal of provide training and education to the residents. Orthopedic residency at HEALF, and at other hospitals in Nicaragua, is much different than in the United States. Residency is only three years, although this has been changed to four starting in 2013. Residents are taught by their attendings primarily by observing in the operating room and during department-wide ward rounds, which occur once weekly. There is one hour per week devoted to didactic resident education, in the form of a basic orthopedic knowledge lecture given by one of the upper level residents. Given the lack of skilled ancillary staff in the hospital, the residents take on many additional duties, such as running the fluoroscopy machine, cleaning the operating room between cases, and making sure all the instruments for each case are available and ready for sterilization 48 hours before the surgery.

 During my time at HALF, I was able to interact with the residents on a daily basis and provide some teaching in the inpatient, outpatient, and surgical settings. They were all very eager to learn how different clinical scenarios would be handled in the United States.

A busy clinical schedule limited my time for sightseeing while in Nicaragua, but a surgical cancellation on Saturday and a day off on Sunday allowed me a weekend to experience the countryside. I spent an afternoon hiking on the Mombacho Volcano overlooking Lake Nicaragua. On my drive home, I was stuck for 90 minutes in traffic after I was detoured off the main highway on account of a huge street carnival that lasted well into the night. I also spent a day exploring the uncrowded, and largely undeveloped, beaches at the southern extent of the Pacific coast, eating ceviche and watching surfers prepare for the upcoming World Surfing Championships.I am grateful for the opportunity to have had this experience and grateful to those who made it possible, specifically the orthopedic department here at Washington University, Health Volunteers Overseas, and Dr Dino Aguilar in Managua.

These trips are an important tradition that can help inspire a sense of international stewardship and facilitate future overseas volunteering. I hope the relationships I formed during my two weeks in Nicaragua will help me with trips to HALF after I finish my orthopedic training.

Monday, May 20, 2013

Bomet, Kenya

By: Charles Lehmann

For my trip I elected to visit a mission hospital named Tenwek Hospital located about 10 kilometers outside of Bomet, Kenya.  Bomet is a small Kenyan village located about a four hour drive west of the capital Nairobi on the far side of the rift valley.  Tenwek serves as the primary hospital for approximately 600,000 people living in many small villages and farms within a 30 kilometer radius of the hospital.  It also serves as a referral center for a much larger radius.  The majority of the people in this area are a native Kenyan tribe called the Kipsigis.

I chose to travel to Tenwek Hospital because there is a United States trained orthopedic surgeon who works at this hospital as a full time missionary surgeon.  I wanted to experience not only what orthopedics is like in the third world, but also what the life of a missionary surgeon is like.  On Saturday, January, 26th I arrived at Jomo Kenyatta International Airport in Nairobi, Kenya.  It was already dark, but thankfully, the driver that Samaritan’s purse had arranged to pick me up was waiting for me immediately after I had obtained my luggage.  He drove me to the Mennonite missionary guest house where I was able to obtain a hot shower and get a reasonable night’s sleep before making the trek to Tenwek Hospital.

The next morning a driver met me and we departed for Tenwek Hospital.  It was a fairly smooth trip by third world standards complete with cattle crossing the highway at numerous points, police officers standing on the edge of the road with machine guns, and a few random roadside baboons and zebras.  After arriving at Tenwek I was given a warm welcome and tour of the hospital and grounds by the orthopedic surgeon that I was going to be working with named Dan Galat.  I quickly realized that it was going to be a busy two weeks since the orthopedic service had greater than 40 inpatients on it and ran 2-3 operating rooms every day during the week.  

Similar to the United States we started the day out with inpatient resident rounds at 6am.  However, prior to starting rounds we had a fairly quick devotional led by one of the residents.  Following resident inpatient rounds we met with the orthopedic attending surgeons and reviewed the x-rays of all of the consults that had come in over the weekend and cases that had been done.  This was performed on a small computer monitor.  (Yes, they do have digital x-rays in the third world.)  Then the entire team proceeded to make other set-of rounds on all of the orthopedic patients that were scattered throughout the hospital complex.  It was remarkably similar to rounds at Washington University other than that we stopped to pray for patients three different times throughout rounds.

After rounds we headed to the operating rooms to start our first case.  We had two operating rooms that were filled with cases.  The spinal’s had already been performed when we arrived and the patients were in the process of being positioned for surgery.  The majority of the OR staff were Kenyan natives, but thankfully all of them spoke reasonably good English making communication much easier.   In the room that I was placed, the first case was labeled AMP.  I assumed that we were going to be amputating somebody’s leg, however I was completely wrong.  AMP stood for Austin Moore Prosthesis (non-cemented, non-modular hip prosthesis – this was one of the original arthroplasty options used some 30-years ago in the United States).  Apparently, this is the cheapest hemiarthroplasty that one can buy (costs $80 from India).  Therefore, working with my mentor Dr. Galat I implanted my first ever AMP.  Another interesting part of my 1st case was that while removing the femoral head, I noticed tumor appearing material in the femoral canal suggesting a pathologic process.  I asked if we should send this to pathology to have it evaluated.  However, I was told not to because this patient was sick and elderly.  Apparently, even if we were able diagnose a specific cancer, the patient would not be able to afford chemotherapeutic medications nor would was their oncologic care that would be readily accessible to them.  Obviously, a very different perspective from how we practice in the United States.  

The second case was a type I open fracture of the tibia and fibula.  We fixed it with a special kind of nail called a SIGN nail.  This is a special stainless steel intramedullary nail designed by a guy in the United States specifically for use in third world countries.  The unique feature of this nail is that you can put the nail in without requiring a fluoroscopy machine.  One is able to do this by reducing the fracture through an open incision.  They also have an extra long jig that allows one to place the distal interlock screws along with several other creative tools that help to ensure that the distal screw is being successfully inserted into the nail.  Despite the lack of fluoroscopy the case went surprisingly well and we successfully placed the SIGN nail in about the same amount of time that it would have take to place an intramedullary nail in the United States.   Following this we did another SIGN nail to fix a closed femur fracture.  We finished in the OR at about 6pm.  Therefore, I didn't have time for much other than eating a little dinner, getting cleaned up, and relaxing for a few minutes before hitting the sack.

The next day I operated with Dr. Kiprono, who was a young Kenyan trained orthopedic surgeon in the 1st year of his practice.  Our 1st case was a SIGN nail on a nonunion of a prior segmental femur fracture.  It was rather tricky to find the femoral canal on both sides of the fracture, but non-the-less we were able to get a nail successfully placed in a reasonable amount of time.  The second case was one that I had never seen before – a chronic elbow fracture dislocation.  Dr. Kiprono let me take the lead operating and I was able to successfully open reduce the elbow.  It was quite challenging, but also quite rewarding at the same time.  Our final case of the day involved pinning an unstable fracture dislocation of a fourth metatarsal.

While the operating room conditions were comparable in many ways to the United States, the wards at Tenwek Hospital were strikingly different.  The wards at Tenwek are large rooms that contain anywhere from 5-25 patients and are separated based on sex and hospital service.  Patient fees for staying in the hospital are approximately 600 Kenyan shillings or a little over $7 dollars per day, plus the cost of any medications that they receive.  In addition, the hospital here has moved towards a payment system where patients are expected to make payment for their surgery prior to any elective procedure - fixing a fracture is considered elective.  For example, a common orthopedic surgery procedure such as fixing a femur fracture costs $50,000 Kenyan shillings ($570 US dollars), which is equal to the median monthly post tax income in Kenya.  In comparison to US healthcare this is extraordinarily cheap, but it is a significant amount of money for many people in this region of the country.  By charging this fee the hospital is able to stay mostly self sustainable, and is also to pay the salaries of the 600 local Kenyans that it employees.  Charging a fee also seems to make the patients much more invested in their care.  

During my two week stay at Tenwek Hospital I ended up performing over 30 cases.  I learned a lot of what it is like to be a missionary surgeon in the third world.  I also learned that sometimes you have to accept different treatment options as good enough based on the resources available to you.  If you are interested in reading more about my experience I wrote a more extensive blog along with my personal reflections during the trip that is outside the scope of this summary.  It can be found at