Monday, February 1, 2016

Panamá City, Panama

By: Jeffrey Stambough, MD
My trip to Central America was a first for me, having never been south of Mexico. Panamá City holds a unique place in the world primarily because of its geography. The country of Panamá is a large isthmus and it functions as a gateway from the Pacific to the Atlantic, thanks in part to the development of the Panamá Canal. Although this modern marvel of sheer engineering brings in over 5 billion dollars to the economy, this only accounts for 6% of their GDP.  The canal is currently in the final phases of a massive expansion that will create a second, larger channel lane to allow larger ships with more cargo to embark on the ten-hour bypass. Needless to say, this will further contribute to expand Panamá’s role in the global trade economy.

Hospital Santo Tomás
Panamanian healthcare in reality is a three-tiered system.  Private hospitals are the desired destination, but can be costly for the average Panamanian whose monthly wage is around $500.  There are social security hospitals, to which all citizen’s taxes contribute, but these facilities often don’t provide the breadth of care most people seek.  Finally, there are public hospitals in the National healthcare service (“Salud), which accept typical fee for service. Hospital Santo Tomás (HST) is the largest of such public hospital in the country and exemplifies this pay for service credo. It was massively expanded in the 1920’s to it’s current 5-acre plot and was originally called the “white elephant” for it’s grandiose size and thought that it was too big to deal with healthcare needs.  Almost, a century later, it’s a 600+ bed hospital that routinely runs a full capacity. 

I traveled with a group, Operation Walk, and we were granted access to a wing of this hospital for a little over a week. Our group consisted of 5 surgeons, 3 anesthesia providers, 4 PAs, a collection of floor/PACU/scrub nurses, physical therapists and volunteers to help with sterile processing, patient transport and other tasks.   We worked exclusively at HST under the direction of our coordinating orthopaedic physician, Karla Morales, MD, who helped recruit patients over the past year as potential candidates for joint replacement. 

Our first day in Panamá was spent conducting an all-day screening clinic for nearly sixty patients. After a thorough pre-operative review, we declined some people for surgery given our limited resources with implants and/or undue surgical risk factors. As a team, we agreed upon 56 patients who we’d then perform the various knee and hip arthroplasty procedures over the course of our week there.

Operating in a foreign country can be a daunting experience if one fears the unknown. Will they have the necessary equipment to properly sterilize the surgical equipment? Will there be enough modern equipment to safely perform anesthesia? Will the rehabilitation equipment be safe? Luckily, we quickly found the answer to these questions was a resounding yes.  HST is a very advanced hospital in terms of available resources and manpower. They have modern anesthetic monitors, fluoroscopy (although not always someone to run it), and portable x-ray that is nicer than most hospitals in the US! The only real problem we ran into during our time there was that the water shut down to the sterile processor after our 3rd day of cases, so we had to all pitch in to scrub down instruments and “flash” trays. And when we ran into issues trying to assess preoperative leg lengths, we got creative and used books old books and journals to act as “blocks.”

As for my interactions with the Panamanian orthopedic doctors, there were 3-4 orthopaedic residents per class who take rotating trauma call and are responsible for covering urgent cases.  Due to the healthcare structure, however, almost all fractures are initially managed with external fixation until the patient can raise the funds to pay for an intramedullary nail or periarticular plate and screws. One PGY-2 resident with whom I had the most contact, Eduardo Camino, was extremely helpful when it came to translating during the clinical interviews and inpatient rounds. His baseline understanding of orthopaedics made it easy for him to navigate those waters, and in turn, made me realize even more that knowing how to speak Spanish would have been huge advantage in my profession.

They use the same text books that we do – Campbell’s Operative Orthopaedics and Green’s Operative Hand Surgey – as well as read the same journals – JBJS, Journal of Arthroplasty, etc. Eduardo and my time together really allowed me to reflect on all of the perks that we have not only with training in the states, but specifically at Washington University.  Our scheduled didactics would be considered a luxury in Panama, as the students I talked with were yearning to learn the breadth of orthopaedics through case-based learning (instead of seeing photos in a textbook).  

In our time at HST, we were able to complete 48 hip and knee replacements in 56 patients. I either led or was directly involved with 15 of the cases. It was an eye-opening experience from beginning to end because we saw people who had such advanced arthritic disease that they often required substantial releases to achieve a balanced knee, for instance. However, using the tools which we had available combined with the perseverance of the patients, all patients were up and walking the day after surgery. One of the physicians brought 100 vials an antifibrinolytic drug, tranexemic acid, which was a Godsend in that in drastically cut down on the need for post-operative blood transfusions, even though most patients started with some baseline anemia (Hgb ~ 10) due to the rampant malnutrition in the country.

What I will take away the most from the mission experience was the seeing the gratitude from the individual patients from the pre-op through the rehabilitation process. Most patients had significant dysfunction preoperatively and had limited access to conservative treatment, such as anti-inflammatory medications. Some patients had fashioned a cane out a piece of wood to help offload the affected extremity. One patient in particular made an indelible impression. The last patient we treated was a 4’4” Franciscan nun who had advanced degeneration of her knee.  Although she was  
in extreme pain and wasn’t able to kneel for the past five years, she was extremely vivacious and happy throughout the entire process. Every morning on rounds, she greeted the team with a smile and hug, which turned out to be infectious in that it served as a constant reminder of the great things that come from our endeavors. While her surgery proved difficult given the amount of fixed deformity and bone quality, we were able to give her a solid, stable new knee. She was so happy she wept the day after surgery. It was a moment that I will take with me throughout my professional career.

Participating with a group like Operation Walk provided me insight into all the good that can come from medical mission trips. It is definitely something that I will look to make time for as part of my professional practice as a joint surgeon.

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