OrthOdyssey

Coimbatore India

2012-01-09T09:22:00.000-08:00

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 (http://www.gangahospital.com/microsurgery/new/institute.html). 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.

Tanzania

2011-11-23T08:19:00.001-08:00

By: Chirag Shah, MD

“Primum non nocere”- First do no harm. As a training orthopedic surgeon I remember taking the Hippocratic Oath as a right of passage however the true meaning of this simple saying never really hit home until my chief year of residency. In order to “First do no harm," one must have the medical education to make the correct decisions and treat within their own capacity. We live in a country and medical system that focuses on patient care, patient satisfaction, resident education, and excellence in medical treatment and therefore we are surrounded by arguably the best medical and surgical care. We often take that for granted. Traveling to Tanzania brought everything into perspective for me and I quickly realized that there is a vast need for international medical education and charitable outreach.

Being raised in a first generation American household, I was always raised with cultural acceptance. After traveling to various international locations, I have expanded my personal interest to pursue international medicine and make that part of my future surgical practice. The opportunity given to me during my chief year of residency, to travel internationally for an elective surgical experience, was one I was looking forward to for the last 4 years. After searching for the appropriate experience, I found the SIGN (Surgical Implant Generation Network) program at the Muhimbili Orthopedic Institute (MOI) in Dar Es Salaam, Tanzania. While preparing for my trip, I don’t think I realized the eye opening experience I was about to have.

When I first arrived in Dar Es Salaam, I was shocked to see the size of MOI. As one of the largest Orthopedic providers in eastern Africa, the hospital has to be large enough to accept patients from near and far. One of the most apparent differences to me when I first arrived was the overwhelming need for trauma care. A new word I learned when in Tanzania, “piki-piki”, was used to describe the relatively cheap motorcycles that were found on every street. Locals did not always have driver’s licenses or the safety equipment we are used to, and this led to a large portion of the blunt trauma injuries that we saw. I still remember my first call Saturday (referred to as “surgical camp”), as we ran multiple ORs staffing femur fractures all day long. I myself was in one room while others residents were in other rooms.

Through the implementation of the SIGN nail, which allows for intramedullary fixation of long bone fractures without the use of fluoroscopy, the treatment for femur fractures at MOI has changed over the last few years. As resources are limited, they have focused on the treatment of these patients and have improved their efficiency and outcomes considerably. Patients with femur fractures are now taken to the OR the day they arrive and are usually discharged on POD #1. This lessens the overall burden on the hospital and allows other patients to use the limited bed space and facilities.

Another eye-opener was the state of the patient wards and the care provided before and after surgery. My first visit to the patient wards was shocking to say the least. Within the public ward (for a majority of patients who lack private health insurance), large rooms are lined with cots full of patients and overflow patients lining the floors and hallways. These patients have family members to help prepare meals and care for them during their hospital stay. After meeting these patients and experiencing their gratefulness, even in the face of such hardship, I truly felt the impact of our contribution from both a surgical as well as educational standpoint.

At MOI, I worked with not only the faculty, but also with residents in training. Over their various levels of training, there was one trait that was common, the desire to learn more. I was constantly asked for more orthopedic resources and was able to share with them some of the Wash U educational curriculum. I was given the opportunity to give a lecture and afterwards, the director of orthopedics approached me to let me know that the most important principle I taught was how to analyze the literature and practice evidence based medicine. Once again, I realized that we take for granted our education system and have so much that we can offer when it comes to the developing world.

As in most of the developing world, limited resources in Tanzania restrict much of orthopedics to trauma and tumor cases. It is with the advent of devices such as the SIGN nail that time and resources can be used for other types of orthopedic cases. That being said, trauma is still the vast majority of care that is provided in this setting. However, even though they are strapped for resources, I quickly learned that amazing care could be provided when there is the will to help and the will to learn. One of the hardest things to deal with in the developing world is that you have to handle cases with what equipment and technology is available. That being said, it’s amazing what can be done with limited resources. I witnessed innovative surgical styles and treatment options for difficult problems during my time at MOI and hope to use that innovative style in my future career. More importantly, I met surgeons at MOI that are training the second generation of well trained orthopedic surgeons in Tanzania, and I was proud to be a part of that effort and hope to continue with this in the future.

Cambodia

2011-03-07T11:18:00.000-08:00

By: Maggie Kuhn, MD

Medicine does not exist in a vacuum. It’s a simple enough concept, and statement for that matter. There are probably hundreds of essays written with this premise every year, by college students eager for medical school acceptance. And how we practice medicine is reflective of our priorities: not only as physicians, but as a society and a culture. I know that I understood this at one time, and I know that I even contemplated in the past. But life gets busy: we get up early, we round early, we see patients and put out fires and attend conference all before a 7:30 am start. We go, go, go, we complain that anesthesia is slow, that the nurses are slow, that the patients aren’t compliant, that the other services don’t really care—and before we know it, we’ve been at this five years.

This experience for me, going somewhere completely foreign and seeing medicine in a completely new context, has been one that has required me to slow down. And slowing down, for me, has proven immensely difficult. Kossimak Hospital has an 80 bed orthopedic trauma unit. But things at Kossimak are different now than they were 2 years ago. Two years ago, the 80 beds were filled—so much so that two visiting surgeons contributed over £150,000 to build a new unit. But two years ago the government changed the compensation structure for surgeons and hospitals. For reasons unclear to me, prices for patient care went up and physician compensation went down. Now, the ward is at least half empty—patients cannot afford the $280 surgery fee, or the $30 a day to stay in the hospital. Most of them go to traditional healers or ‘bonesetters’ for their initial care. Otherwise, they go to the less expensive and closer provincial hospitals. This poses two problems. First, their care is not as good: resources are even more limited and physicians are less trained. Secondly, appropriate care is delayed—when the patients finally do present, it is months or years later, and fractures have become nonunions or, worse, malunions, elbows are stiff, joints are contracted, and the patients have lost their jobs.

Despite this, the dedicated surgeons at Kossimak continue to operate as much as they can. Four of the five operating rooms on the campus are dedicated orthopedic rooms, treating almost exclusively trauma patients. The crowdedness of city streets, the prominence of “motos” or scooters, and the lack of traffic laws (or, at least, their enforcement) make for plenty of business. The surgeons at Kossimack, and especially their dedicated chief of staff, Dr. Bunn, have done more SIGN nails than any other institution worldwide: over 1,300. The nail itself allows for long bone fractures, which are by far the most common orthopedic injuries seen in Cambodia, to be treated with intramedullary fixation. In the US, this fixation technique is frequently utilized in order to stabilize fractures internally and to allow patients to ambulate early after surgery. The alternative is the time tested and reliable “traction” technique, whereby patients with lower extremity fractures are maintained in bed, with traction applied to the affected extremity, until they heal—often upwards of 8 weeks.

Conditions in the operating rooms are sparse. There is air conditioning, but no running water in the rooms. Drapes are cloth and, often, rattled with holes that require multiple adjustments to maintain a sterile field. The surgical trays are sparse: one drill, but otherwise without power tools. There is one needle-driver and one knife blade per set, and generally very little uniformity to the trays themselves. All bone reaming and screw placement is done by hand, and all screws have to be hand tapped. Probably the most glaring difference with respect to the operating room setup is the fact that fluoroscopy is notably absent from nearly all procedures. Of all the frustrations I encountered trying to acclimate to a different system of operating and of administering health care, this was likely them frustrating. Lack of fluoroscopy, or intraoperative x-rays, is not uncommon in the developing world. In fact, the SIGN nail was developed expressedly to avoid the need for fluorography in the OR. But Kossimack hospital has two fluoroscopic machines, one in each of 2 operating rooms, which have been donated. Despite having the machines, the surgeons are exceedingly reluctant to use it, as many believe its use will make them impotent.

It is the care before and after surgery, however, that was most disparate from my own experience. If you were to sustain a femur fracture in Cambodia, say from a moto accident, your family would drive you to the hospital—in a car if you had one, but more likely on the back of a moto or a bicycle. If you had insurance, you could stay in the air conditioned rooms, but if not, if you’re like most Cambodians, you would be escorted to a room with 8 beds, a fan and no linens. For $30 a day, you could stay in the hospital and be provided IV drips, medications and dressings for your wounds. Your family would have to pay this daily fee on a daily basis—actually to the physicians themselves. Food and water, of course, are not covered, and families provide these for patients. Similarly, while nursing care is available for dressing changes and medication administration, family members bear the burden of moving patients to and from bed, changing bed pans and getting the patients up on their feet and beginning basic physical therapy. Not food, of course.. If you needed surgery and could afford the $280 surgical cost in addition to the cost of the implant used, your surgery would be scheduled two or three days after your admission. Your chance of contracting a post-operative wound infection would probably approach 10% if you were young and healthy, and your hospital stay would be about 5 to 7 days (or, as many days at you could pay for.) While these costs seem dramatically low, they are relatively high for Cambodian citizens, many of whom make less than $1,000 annually. Surgical orthopedic care is prohibitively expensive, and many patients simply cannot afford to come to the hospital, at least not initially.

The concept of outpatient care, both pre and post-operatively is a relatively new one at Kossimack. The surgeons there, with the help of World Orthopedic Concern, have recently established an outpatient clinic where patients can be seen. The concept, however, has not yet caught on with patients, many of whom have difficulties returning to the hospital due to lack of transport or job/family requirements during the day.

There are a host of things that I’ve taken away from this experience that I found profound, particularly as I reflect upon them having returned to my comfortable, efficient, wealthy hospital. The first is that it’s very difficult for me, as a surgeon, as one trained to be productive and to fix problems, to work in an environment in which efficiency is not optimized. I found myself, in Cambodia, constantly looking for the next case, trying to find more to do. The pathology is plentiful, but the resources and infrastructure are not: both on the patient side and on that of the hospital. The reality of this, however, was that I had to slow down and observe, think, talk to people and try to get the slightest sense of what it means to be Cambodian. More so even that operating, my favorite part of the day was board rounds with the staff surgeons, residents and medical students, the time each morning when we all gathered to review the week’s cases and discuss treatment plans. This was the time of day when I was most aware of just how much these well trained surgeons are forced to make medical decisions based on non-medical considerations: patients who cannot afford surgery with distal radius fractures get percutaneous fixation under regional anesthesia, patients who I would recommend for operative fixation with plates receive ex-fixes because no plates are available, anywhere in the country. It becomes difficult to define “standard of care”—that standard is so dependent, on patient finances and resource availability.

In the five years since I became a physician, I have, for the most part, stopped noticing just how profoundly our culture is intertwined with the way we practice medicine. The American medical infrastructure is enormous: it is legislative, administrative, medical, financial, intellectual, judicial and even religious. But what would medicine be if there were no government, no legal system, no money, no laws, no religion, no family? And how would you practice it outside of these entities?

When Pol Pot’s regime crushed Cambodia, it crushed not only a people, but an entire infrastructure. And now, thirty years later, the surgeons at Kossimak Hospital are desperately trying to practice medicine with an infantile infrastructure. There are patients, and there is pathology everywhere, and there are physicians who want to fight it. And in this situation, particularly as a surgeon, it is tempting to start formulating a plan—figuring out how we, as Americans or as western surgeons, can show these people how to succeed. But that is a delicate and dangerous thing. It is tempting to see the world in black and white, with good or bad fixation, with good or bad results—but this experience is teaching me that even those are relative.

Blantyre, Malawi

2011-02-10T11:11:00.000-08:00

By: Corey Gill, MD

Malawi is a landlocked country in sub-Saharan Africa. It is known as the "Warm Heart of Africa" and I have certainly felt this to be the case in my 3 visits to the country since 2002. Before writing about my recent remarkable chief resident experience at an orthopedic hospital in central Malawi, I would first like to briefly mention some aspects of Malawian culture and the unique travel experiences I have participated in during my visits there. Malawi is a former British colony that gained its independence in 1964. The largest ethnic group is the Chewa, and the predominant local language is Chichewa. The primary source of food in Malawi is corn, which is milled and then cooked into a product called nsima. Nsima looks and tastes similar to the grits I grew up with in the Southern United States, and is eaten at virtually every meal. Malawi is partially bordered by the large and appropriately named Lake Malawi. The lake is home to 80% of the aquarium fish in the world (cichlids), and there are a number of beautiful towns to visit along the lake's borders. There are a number of great national parks in Malawi and neighboring countries where one can see wildlife such as elephants, hippos, and lions. Malawi is located along the Eastern Rift Valley, with mountains and dramatic elevation changes seen between the northern and southern ends of the country. This geography is great for activities such as mountain biking. I was fortunate to participate in a 70 km off-road biking day trip with one of the head orthopedic surgeons on my recent trip there.

Despite its cultural riches, Malawi is one of the poorest countries in the world, with few natural resources and a life expectancy of approximately forty. There are 6 orthopedic surgeons in the country serving a population of 15 million people. In contrast, there are approximately 1000 orthopedic surgeons in the United States serving 15 million people. For my international rotation, I travelled to the BEIT Trust CURE international pediatric orthopedic hospital in Malawi's largest city, Blantyre. This charity-run hospital is staffed by 4 pediatric orthopedic surgeons who perform over 1000 procedures each year on Malawian children with a variety of conditions including: angular limb deformities, chronic osteomyelitis, untreated clubfoot, metabolic bone diseases, burn contractures, and orthopedic tumors.

The difference in care of orthopedic conditions in children in Malawi and the United States is dramatic. Fractures, such as supracondylar humerus fractures, are rarely treated surgically for a variety of reasons. There is not enough manpower to perform the surgeries, orthopedic implants are very limited in supply, and children often don't present to the hospital for weeks to months after their injuries. For example, shortly before I returned home, I saw a 14 year old child who fell out of a mango tree one year prior to presentation and complained of pain with walking. X-rays revealed an obvious displaced femoral neck fracture, a condition that would have prompted a trip to the emergency room shorty after injury 100% of the time in almost any city in the United States. For many of the conditions that I saw during my visit, presentation to the hospital occurred much later in the disease process than in developed countries. Children with osteomyelitis often had major sequelae of their infection such as large areas of involved bone requiring resection, children with clubfeet were often untreated as infants (although this is beginning to change significantly after institution of a nationwide nonoperative treatment program using the Ponseti method), and children with orthopedic tumors often did not present to the hospital until a large soft tissue had been present for many months.
Despite the severity of conditions seen in many children, the orthopedic surgeons and nurses that I worked with were often able to cause dramatic changes in the lives of the children and families seen at the hospital. Because their conditions were often severe with significant associated morbidities, surgeries that even partially improved or corrected various orthopedic pathologies dramatically improved the quality of life of these children. In addition, there is a large amount of stigma associated with orthopedic diseases in Malawi such as angular limb deformities, polydactyly, or joint contractures secondary to infection. Children with these conditions are often seen as cursed or bewitched by other members of their community and ostracized by the villages they live in. Educating parents that their children are not cursed gives them comfort and relief, and improving their childrens' cosmetic deformities better enables them to reintegrate into their communities in addition to improving their clinical function.
I was amazed during my visit at the level of stoicism, maturity and gratitude displayed by young children treated with major surgeries. For example, we performed an above-the-knee amputation on a 10 year old girl with an osteosarcoma (malignant bone tumor) of the distal femur. Despite receiving only Tylenol for pain, she was thanking us on post-operative day #1 for taking care of her and walking around on crutches with a big smile on her face. Another child with an unknown metabolic bone disease being treated with a Taylor spatial frame for a failed attempted knee fusion sustained a fracture of his femur above one of the pis from his frame. The orthopedic surgeon who performed his most recent surgery told the patient he was sorry that he was having to go through with so much, and the patient replied by trying to comfort us. He said, "Don't worry, everything will be OK."
In addition to my time at the pediatric orthopedic hospital, I spent some time at the adult hospital across the street. Surgical orthopedic care of adults at this hospital is minimal, even when surgeries are indicated. OR time is sparse, anesthesia care is suboptimal, stores of orthopedic implants are minimal (the day before I left, one of the orthopedic surgeons had to tell a patient with a Galeazzi fracture dislocation that surgery could not be performed because there were no plates in the hospital at that time), and patient triage is difficult (patients often sit in the hospital for weeks with a fracture before an orthopedic surgeon is told about them). In the face of these multiple difficulties, the one dedicated adult orthopedic surgeon in the country does remarkable work caring for the patients he is able to, but the situation is certainly appalling. I asked one of the orthopedic surgeons I worked with what happens to people with significant orthopedic injuries like open fractures from road traffic accidents (a common problem in Malawi) that need orthopedic intervention. He replied candidly "If they are lucky, they die at the scene."
While improving orthopedic care in developing countries is faced with difficulties at multiple levels such as appropriate triage of patients, remarkably insufficient number of surgeons, and gross inadequacies in healthcare infrastructure, I do not think this provides an excuse for apathy or maintaining the status quo. While we as residents are generally not able to dramatically impact patient care during our relatively short visits to places like Malawi, Mongolia, or Nicaragua, we certainly come away from these experiences with a new perspective and appreciation for the types of care available in the United States. These experiences highlight for us the need for resources, manpower, education, and infrastructure to improve orthopedic care in developing countries and hopefully will make us more likely to participate directly in this improvement during the course of our careers. In the short-term, we can educate other orthopedic surgeons and the community as a whole to the need for awareness and monetary donations to organizations like CURE internation (www.cure.org) or SIGN (www.sign-post.org) that are actively improving the care of thousands of pediatric and adult patients in developing countries around the world.

My International Rotation

2010-12-10T09:53:00.000-08:00

Lindley Wall

Hospital Fonseca, the public hospital where I spent my first week.

For my international rotation I traveled to Managua, Nicaragua, in conjunction with the organization Health Volunteers Overseas (HVO). During the first week, I worked with the Nicaraguan orthopaedic surgery residents at the public hospital in Managua. Each day was a combination of clinic and operating; beginning with fracture conference at 6:30am and ending with evening rounds on all the patients with all members of the orthopaedic team. While there were some elective surgical cases, most cases were infections and fractures. A few of the cases I participated in included fixation of femoral shaft, tibial shaft, hip, and distal radius fractures. The supplies available to the residents at the hospital were very limited, but they took great advantage of the accessible resources, using all instruments and implants available. Unfortunately, it is a common scenario that patients would have to remain as inpatients awaiting arrival of implants or depending on their family to find the money to purchase the appropriate implants.

Clinic waiting room at the children’s hospital.

At the start of the second week, I was joined by the HVO hand team, lead by Drs. Michelle James and William LaSalle. This was the third year HVO had sent a hand team to Nicaragua to teach and operate at the local hospitals. The group consisted of two hand therapists, three hand surgeons, one pediatric orthopaedic fellow, and two orthopaedic residents. We worked in two teams, one working at the military hospital, seeing adult patients, and the other treating children at the pediatric hospital. The week began with a full clinic of patients at each hospital; this included post-operative visits, therapy sessions, initial evaluation and diagnosis, and scheduling the operative cases for the week. Each of the following days that week, we were able to perform approximately four surgeries per day at each of the two hospitals. The range of cases was incredibly broad, from a 9-month-old baby with a cleft hand at the pediatric hospital to a 65-year-old woman with RA who underwent multiple MCP joint arthroplasties at the military hospital.

Distal radius fracture at Hospital Fonseca.

Drs. Michelle James and William LaSalle with the Nicaraguan residents.

Overall the goal of the trip was to help take care of the Nicaraguan population and to teach the Nicaraguan orthopaedic surgery residents how to diagnose and treat adult, as well as pediatric, hand conditions. Each morning a member of our team would give a lecture on general hand topics for the residents. Subsequently, we would proceed to the operating room where the HVO surgeons would take the Nicaraguan residents through the operative cases. This provided a great opportunity for the residents to see how we treat a wide variety of hand pathologies, including hand trauma, degenerative conditions, and congenital malformations of the hand and wrist.

The HVO Hand Team

In addition to the clinical aspect of the trip, the social and cultural experience was invigorating. While there was limited time for sight-seeing, given our clinical schedule, we were able to spend one afternoon in Granada, a beautiful, historic city. Our Nicaraguan hosts were more than accommodating. The residents and attendings with whom we worked were very welcoming and gracious, taking us to the local restaurants to experience their culinary culture.

The beautiful historic city of Granada.

Enjoying the culinary culture of Nicaragua.

I appreciated the opportunity to practice orthopaedic surgery in Nicaragua, to improve the patients’ lives there, and to learn how programs, such as HVO, are organized and implemented. Hopefully in the future I will be able to participate and contribute as an attending hand surgeon, treating the local population and teaching residents new tools to improve patient care in their own countries.

My International Trip to the Dominican Republic

2010-07-19T07:20:00.001-07:00

By: Nathan Mall, MD

I traveled to the second largest city in the Dominican Republic, Santiago de los Caballeros. I arrived at midnight and started to work bright and early the next day at the Hospital Universidades Jose Maria Cabral y Baez. This hospital is the only teaching hospital in Santiago and functions much in the same way as teaching hospitals in the United States. I learned a great deal from their residents about their health care system, their struggles to bring appropriate orthopaedic care to their patients, their culture, and their friendship.

Some believe Santiago was founded by Christopher Columbus, while others believe that it was part of the first wave of European colonization but may not have been founded specifically by Columbus. I was able to go to the Centro Leon, which is a museum devoted to Dominican culture and ancestry. Originally, this area was used for sugar production, but now relies on telecommunications and tourism to contribute to the countries GDP.

They have a very famous baseball stadium called Estadio Cibao, home of the Aguilas Cibaeñas baseball team. The Dominican Republic hosts many major league baseball players during their winter league play.

Culture

In my time in the Dominican I got a feel for their culture. They truly enjoy life and enjoy eating, drinking, and their music.

The culture is much more expressive than ours, except when it comes to pain. I only twice heard a patient express pain while I was there, one was an elderly woman who yelled in pain, the other was a young man that had surgery the day before and was asked to come to conference and move his arm and he simply said that it hurts, but did not grimace, scream, or cry. The people are very flamboyant and passionate. They speak loudly and are not afraid to speak their opinions. They are very giving despite having very little. The people work hard but also enjoy life. Whole neighborhoods would be out on the street playing dominoes, laughing, drinking, and enjoying each other companionship. There is a large disparity between the rich and the poor, with very little in the way of a middle class. The poor are very poor, some with broken bones cannot afford to have a cast put on. I asked how much it would cost in US dollars for a cast, and it was two dollars. The rich drive very nice cars and live in nice homes and usually have second homes at the beach or in the mountains.

Health Care

Many patients that would like to seek treatment have to arrive at the hospital by five o’clock in the morning. They wait in long lines to be registered and are then allowed into the hospital. For more urgent patients there are two Emergency rooms, one for internal medicine and one for trauma and surgery. The Emergency room is dominated by orthopaedic patients, most with long bone fractures from motorcycle accidents or gun shot wounds. They are seen in the emergency room by the residents who will put them in traction using a Steinman pin and two milk jugs filled with water for weights. They then await a bed, which can take hours to days.

There are around 50 patients or more lying in rooms in the hospital for months as they try to come up with the money to pay for the treatment that they need. Some cannot, and they lay in traction for 6 weeks or more. Because of this problem, many of the patients who get surgery have fractures that are malunited, angulated, or infected. This only makes the already difficult problem of operating with limited resources that much harder. The average time from the fracture to the time the surgery is performed was at least 3 weeks.

Radiographs are often one or two views of a particular injury, they are often malrotated, and the patients have to hold onto their own xrays. They are kept under their beds, however the patients also eat in their beds and so many of the xrays get wrinkled from lying on them or food spilled on them. Patients must pay for their own radiographs, CT scans, and MRIs and thus they must be very careful about what they order.

However, there is a large disparity between the public teaching hospital and the private hospitals. The private hospitals have much better radiographic capabilities, better operating rooms, better equipment, and better implant choices. However, these hospitals serve the minority of people in the country.

Surgical Treatments

The operating room conditions are bleak. At the beginning of the case the air conditioning is turned on, and if it doesn’t work they cannot use that room. Trays are incomplete, some even without knife handles. The surgeons must either use the scalpel by hand or use a clamp to hold the knife blade. The nails are of limited sizes and they use the one that fits the best, but this may be 4-5 cm shorter than it should be because the next size available is too long.

The screws are often too long or short as they may have only four or five different lengths available. External fixator parts are removed when fractures are healed and are washed and sterilized and then used in the next patient that needs one. However, despite all of this, the reductions they achieve and the care of the patient is amazing for the resources they have.

Patients with lower extremity fractures typically undergo spinal anesthesia and must sit up on the bed despite their fractured extremity. The patients are usually wide awake during surgery with minimal sedation, however, they never complain or scream in pain. Infection is always a concern because there are four patients in a room, some with infections and there is no isolation like in the United States. They prep and drape the patient in the best way they can. Drapes are cloth as are the gowns and are reused after being cleaned and sterilized.

Residents

The residents care deeply for their patients and are doctors for all of the right reasons. They want to help the poor people of their country and want the best for their patients. Residency is 4 years, and they take call sometimes every third night. Their call room has air-conditioning, but also has a leaking ceiling and bunk beds that don’t appear to be the most comfortable. However, they rarely use them as they are typically very busy when on call. The classmates are very good friends and almost all of their pictures are with each other. The work very hard and play hard too.

The fourth year residents are typically the ones that do the majority of the surgeries, usually with no attending physicians around. The 3^rd year residents operate occasionally, and the second year residents are only in the OR to help prepare the room and the patients, to transport the patient, and perhaps may scrub in to pull traction. The rest of the time they are seeing the massive number of people that come through the clinic and the emergency room. The residents have to do everything themselves, they set up the rooms and cases, they act as their own scrub nurses, they assemble their implants, and transport the patients. They have nurses, but they often do not bother to come in the room during the cases.

They are paid by the government and make about 6,000 dollars a year or $500 a month. Most of the residents still live with their families. There is no 80-hour work week. If they make a severe mistake they are punished with 48 hours straight in the hospital and for more minor mistakes they have to write a particular sentence like “I will not lose the patient’s x-rays” one thousand times. Other punishments include giving extra conferences, and they have a new one of translating the materials I left for them into Spanish.

All of the residents care deeply about learning and are very educated in orthopaedics, especially orthopaedic trauma. Despite the language barrier, I could tell that they really understood many of the more advanced principles in orthopaedics. They did lack some knowledge in sports medicine, oncology, and pediatrics. However, this is not because of lack of effort but lack of resources. They do not see these problems commonly and the most recent journal article they have is a 2006 Journal of the American Academy of Orthopaedic Surgeons.

They also have other humanitarian interests, and one resident even started a foundation to help even more people. When he gets done working way more than 80 hours a week, he then works with his foundation to distribute food as well as to try to get more people access to health care. They are in desperate need of equipment, especially spine, arthroplasty, and arthroscopy equipment and implants, as this is difficult for patients to afford and to bring in to the country.

The residents treated me much better than I could have every expected, making sure I have plenty to eat and drink. They took me out almost every night and really took care of me. For this I will always be very appreciative. I am amazed at their love for life, their country, and their work. It is a hard system, and it would be easy to become complacent or frustrated, but they keep working to being the best health care they can to the people of their country.

From this experience I was able to see first hand how good things are in the United States, and that our physicians and patients take this for granted. The thirst for knowledge that the residents I met had was inspiring, and will help me to study harder, learn more, and take advantage of the resources we have available in the United States. I was able to help with two medical missions while in college, and this trip has reaffirmed my dedication to continuing to serve developing countries when I complete my training. I learned a great deal about the Dominican culture and their respect for physicians, and I only hope I can continue to aid in education and training of these new friends of mine.

Bologna, Italy and Ghent, Belgium

2010-06-15T13:59:00.000-07:00

By: Nirav Shah

During the last year of my residency, I was fortunate to be able to travel abroad and participate in orthopedic care internationally for two weeks. I recently visited the European cities of Bologna, Italy and Ghent, Belgium to work with sports specialists focusing on cartilage restoration. As many of our surgical procedures are derivatives of European techniques, I welcomed the opportunity to interact with surgeons who are contributing novel ideas to the orthopedic field.

My travels began in Bologna, a city in Northern Italy and home to the oldest university in the Western World, founded in 1088. Its location as a central hub for European travelers throughout history led to its development into a major academic and cultural center. Unfortunately, its location has also led to numerous episodes of near complete destruction throughout history, most recently with Nazi bombings in 1944. Every episode, however, was met with resurgence by its populace, regenerating itself as a commercial, industrial, and communications center. It is a city that prides itself in its history, wine, and food. With 375,000 inhabitants in the city currently, and another 600,000 in the surrounding countryside, it is a city that bustles from dawn until well past sunset.

During my time there, I was able to explore the city both historically and gastronomically. It is a predominantly Catholic city, filled with churches, seemingly at every corner. As I visited during the Easter holidays, I observed many parades, celebrations, and ceremonies. After leaving church, the people like to gather in one of the many piazzas to have a drink or a cup of gelato. Gelato is such an integral part of Bolognese life, a “university” dedicated solely to training chefs on its production has been established in the city. The people also take pride in their unique flare to Italian cooking, a treat of which I was happy to partake.

When I was not exploring the city, I was at the Rizzoli Orthopedic Institute, a hospital specializing in orthopedics and musculoskeletal care founded in 1896 within the confines of the historic monastery of San Michele in Bosco. The hospital consists of nearly 100 faculty members with 60 supporting residents who see 150,000 patients and perform 18,000 surgeries annually. Historical contributions include bone tumor classification and management by Dr. Campanacci, treatment of spondylolisthesis by Dr. Marchetti, and shoulder stabilization techniques by Dr. Putti. Current work at the Rizzoli Orthopedic Institute, as evidenced by its presence as the largest tissue bank in Italy, includes allograft reconstruction following extremity sarcoma. The faculty is also in the midst of developing implantable biocomposite materials to repair articular lesions as well as replace previously resected meniscus.

I was thankfully able to observe several gifted knee surgeons such as Dr. Stefano Zaffagnini and Dr. Maurilio Marcacci and engage in enlightening conversations regarding their ideas and thought processes on ligament and cartilage reconstruction. In addition, their residents were extremely welcoming, escorting me around the hospital as well as the city. Seeing Bologna from a resident’s perspective was certainly a welcome and inebriating experience.
After my week in Bologna, I took a short flight and long train ride to Ghent, Belgium by way of Brussels. Despite having Dutch as the official language, the region of Fleming in the northern half of the country, where Ghent is located, has a preponderance of English-speakers, to my relief.

The city of Ghent was first inhabited as far back as the Stone Age due to its location at the confluence of two large, Northern European rivers. Today, it is home to 250,000 citizens and 600,000 total people in the metropolitan area. It has served as the center of the wool trade in Europe (leading to the good relations between Belgium and both England and Scotland), the seat for the high court of Belgium, and most recently the location for the Treaty of Ghent ending the War of 1812 between Britain and the United States.

The city of Ghent is extremely navigable, either by foot, or by its extensive public transportation system consisting of trams and buses. This was extremely helpful as I wandered the streets of the city center, taking in the preserved medieval architecture. One of the most scenic locations is the Graslei, site of the old harbor, where the old post office is flanked by St. Michael’s bridge, and the towers of several churches can be seen in the background.

But the city is not one large museum devoted to past architecture; the inhabitants reside in those same ancient buildings. They come out in droves in the afternoon, as early as 3 pm, to indulge in their favorite drink: beer. The region is famous for its Trappist ales, beers produced entirely within the confines of a monastery to fund the monks’ works. As a charitable citizen of the world, I was more than happy to contribute my fair share to their good cause. The appreciation for the food of Ghent, however, required pride that could only come from Ghent citizenship. The diet focuses on soups and stews to carry through the long, cold winters. Thankfully, its presence as a major port city as well as home to a large university has brought international flavors and cuisine to its people, including a new Subway fast food restaurant.

During the days, I was able to spend time with Dr. Peter Verdonk, an acclaimed sports surgeon whose research focuses on meniscal transplantation. He is part of the faculty at the Ghent University Hospital, a center that is committed to orthopedic resident education and excellent patient care. That philosophy parallels that of my experiences at Washington University. The resident participation in clinical care was nearly identical to that of Washington University, with morning conferences dedicated to education, autonomy in clinic, and supervised progression in the operating room. Our treatment algorithms were also nearly synonymous, save for the differences inherent in a socialized health system compared to our private insurance system. As the healthcare bill had just recently been passed by Congress at the time of my visit, this opened up a lively debate about the merits of each system. I was happy to see our European counterparts considered their system to be broken and unsustainable and looked to the U.S. system for solutions.

I am extremely grateful to everyone who extended their hospitality in both Bologna and Ghent. Over the two weeks abroad, I came to an appreciation for the differences in healthcare, both clinically and economically, that exists across the Atlantic. I found the entire experience enriching and am very thankful for the opportunity.

Lyon, France

2010-06-09T07:08:00.000-07:00

By: Julienne Boone

During the last year of our residency training, we are supported by the department to partake in an international elective for 2 weeks. I recently traveled to Lyon, France to work with internationally acclaimed shoulder surgeon, Dr. Gilles Walch. Ironically, while this experience was not in a third world setting, I was the only chief this year to have significant travel problems and spent an extra week in Lyon due to multiple fight cancellations from the ashcloud of the erupting Icelandic Volcano Eyafallajokull.

Lyon is a vibrant city with a unique architectural, cultural and gastronomic heritage. The city proper has about 470,000 inhabitants, but the area of Greater Lyon has a population of about 1,200,000. It is shaped by its two rivers, the Rhone (to the East) and the Saone (to the West). It is located approximately 285 miles Southeast of Paris, 98 miles West of Geneva, and 200 miles North of Marseille and the Cote d'Azur.

During the renaissance, Lyon was one of Europe's largest cities and its first financial place. It's main industry was silk weaving which remained prominent until the end of the 19th century, and it was interesting to explore Vieux Lyon (Old Lyon) to see the traboules (corridors which link two streets through a building) where the pieces of silk were carried amongst the workshops and to the river. These notable architectural features also played a significant role during World War II under the German occupation as they permitted la Resistance to travel undetected and exchange information/weapons since the Germans did not know them very well. As an interesting fact, the head of la Resistance, Jean Moulin, was arrested in Lyon on June 21, 1943 during a meeting with Resistance leaders and notably interrogated in Lyon by the head of the Gestapo, Klaus Barbie (famously known as "the butch of Lyon").

Lyon is a very easy city to navigate on foot and the public transportation system is unparalleled as well. The metro runs city-wide and made it very easy for me to get to the hospital and clinics as well as explore. I was able to see a multitude of cultural landmarks both historical and present day that speak to Lyon's character.

Food is a very important part of the French culture here and Lyon as been called by many the capitol of gastronomy. Everyone here closes their shops and takes a long lunch break (usually from noon to 1:30ish) to eat at a local Bouchon.
I sampled many of the Lyonnais specialties, including quenelles de brochet (a souffle-like dumpling with pike fish), saucisson Beaujolais (local sausage cooked in red wine), and salad lyonnaise (mixed greens with lardons, croutons, a shallot vinaigrette, and topped with a poached egg - delicious!). All meals are typically served with wine and I was able to taste many fantastic wines produced from the nearby regions of Cotes du Rhone, Burgundy and Beaujolais.

France has universal health coverage through the public health insurance system which pays for about 75% of the total health expenditures. Supplemental private insurance and patient costs contribute to the remainder. There are both public hospitals (non-profit) and private hospitals (for-profit). I spent two weeks with Gilles Walch seeing patients in clinic, assisting with operative cases and attending morning conferences. The hospital he predominantly operates out of is Hopital Prive Jean Mermoz, which is a private 260 bed hospital which opened in 2008. He operates on Tuesdays and Wednesdays and usually does 5-6 cases each day.
He is a shoulder specialist, so the majority of the patients we saw had shoulder arthritis, instability or cuff pathology. Interestingly, all of his patients are admitted the night before surgery for their "pre-op" workup, and then they all stay at least one night post-op (even the cuffs!) since it costs the same regardless of length of stay.

During my time in Lyon, I assisted with many arthroscopic cuff repairs, a couple of Laterjet procedures, and a few total shoulder arthroplasties.

Each morning, prior to the OR, Dr. Walch met with his fellow, Allan Young from Australia, and his partner's fellow, Roberto from Brasil, to review the day's indications and provide some informal teaching. (This was also the time for everyone to have their morning espresso!)

On Mondays and Thursdays, I accompanied Dr. Walch during "consultation" (clinic). He belongs to a private group of 11 (soon to be 13) MD's, including 4 shoulder surgeons, knee surgeons, spine surgeons, a rheumatologist, and a few rehabilitation physicians. They own their own building, Centre Orthopedique Santy, and have in-house radiology and physical therapy.

Consultation occurs in Dr. Walch's personal office, where he has an exam table. Patients are called in one at a time and about 20-30 are seen each day. He works very closely with Dr. Jean-Pierre Liotard, a rehabilitation physician who focuses exclusively on the shoulder, and who sees all of his post-op patients. On Fridays, I worked with Dr. Liotard doing injections and post-op visits to assess rehabilitation progress.

My trip to Lyon was a wonderful experience. Dr. Walch is not only a tremendously talented
surgeon, but he is also an amazing teacher. Everyone I met, from his OR staff to his partners, were very welcoming and made me feel as through I was a member of Dr. Walch's team.
Dr. Walch also welcomed me to his house several times. As football (soccer) is huge in Europe and one of his favorite sports, he had the fellows and me over to watch the matches (we watched Lyon beat Bordeaux in the European Champions League quarterfinals)! Overall, I am very grateful for this opportunity to work with Dr. Walch. Both his professional and personal hospitality were quite gracious and this will hopefully be just the beginning of a wonderful collegial relationship.

Pune, India and Kathmandu, Nepal

2010-04-26T10:26:00.000-07:00

By: Ravi Bashyal

As part of our residency training experience, we have the privilege of taking part in an international experience that allows us to participate in orthopaedic care overseas. I was fortunate enough to spend time with wonderful orthopaedic surgeons in India and Nepal.

The first week of my experience took me to the Sancheti Institute for Orthopaedics & Rehabilitation (SIOR) in Pune, India. Pune is a vibrant city of about 5 million people about 163 km (101 miles) east of Mumbai. I had the pleasure of spending much of my time with Dr. Parag Sancheti, the current chairman of SIOR.

SIOR has made a strong commitment to orthopaedic resident and fellow education, and many of my experiences there paralleled my training experiences at Washington University. Just as we do here in St. Louis, we began each morning at 6:30am with a morning conference on a specific educational topic, followed by an interactive "board rounds" where ER admissions, pre-operative cases for the day, and post-operative cases from the day before were presented by residents and discussed by the entire group. During my time there, we had a lot of interesting case discussions on treatment options of fairly common orthopaedic injuries. I found that in my situations, our thoughts and algorithms were almost identical. However, in some cases, we found that treatment philosophies, hardware availability, and even differences in patients' cultural/social standards led us down varied treatment paths. This all made for very lively debate, and I learned a great deal from participating.

I was able to participate in the OR and clinic as well. Most of my time was spent observing and assisting in various total joint arthroplasty cases. I enjoyed my time at SIOR, and remain thankful for the gracious hospitality extended to me by everyone there.

From India, I made a short 2 hour flight to Nepal, the rooftop of the world, and home of Mount Everest. The flight itself was spectacular, with amazing Himalayan vistas in every direction. Upon arrival in Kathmandu, I was greeted by Dr. Binod Bijukchhe, who was my main host during my time in Nepal. I had arranged my trip with Dr. Ashok Banskota, one of the co-founders of B&B Hospital in Kathmandu. In addition to founding one of the leading teaching hospitals in Nepal, Dr. Banskota spearheaded the creation of the Hospital and Rehabilitation Center for Disabled Children (HRDC) in nearby Banepa. Established in 1992, HRDC is a unique collaboration between Nepali physicians, the Nepalese Government, and domestic and international donors to provide care to Nepali children while also training future orthopaedic surgeons.

Nepal ranks 115th in the world for adjusted GDP, and the economic hardships faced by many of its rural citizens are extreme. For children, this translates into limited access and availability to adequate medical care, including orthopaedic treatment. HRDC attempts to address these issues by offering access to low or no-cost quality orthopaedic care for Nepali children.

During my time in Nepal, I was able to spend tie at HRDC as well as B&B Hospital. At HRDC, I was able to observe and participate in the pediatric orthopaedic care of indigent Nepali children. At B&B, I was able to work with orthopaedic surgeons in a high volume acute trauma setting. Both provided me with valuable insight into the similarities in education and dedication of the residents and staff, as well as the disparities in resources between the US and Nepal.

The most striking memories I took from my experience in Nepal were from HRDC. Everyday, I interacted with patients with orthopaedic issues that are rarely, if ever, seen in America. The lack of access to care can result in neglected injuries that present significant challenges to both surgeon and patient. Though the hurdles to proper treatment may have seemed insurmountable, I found that both the physicians and patients had boundless enthusiasm, patience, and dedication to help them achieve their goals.

My entire international experience was enriched by the fact that my hosts in both countries were so welcoming and hospitable. The lessons learned from my interactions with patients, staff, and residents were one of a kind, and could only be gained by spending a significant amount of time with them. It also became clear to me how much more can and should be done to help advance orthopaedic care for patients in less advanced health care settings. I am grateful that I had the support to be able to participate in such a program during my residency, and I am sure that I will be returning overseas numerous times in my career.

Ulaanbaatar, Mongolia

2009-11-23T07:01:00.000-08:00

By: Jakub Langer

I recently traveled to Ulaanbaatar, Mongolia, as part of my chief year orthopaedic international experience. I spent two weeks at the National Trauma and Orthopaedic Research Center of Mongolia, assisting with operative cases, seeing patients in clinic, and attending conferences. I had the opportunity to give several talks about very common put poorly understood topics, including non-unions and distal radius fractures. I was able to procure some much-needed equipment for the Mongolian surgeons prior to my travel, and brought 30-some pounds of nails, screws, drill bits and plates with me. I had the privilege of assisting with the placement of the first two locking plates in Mongolian history.

The Mongolian surgeons were very welcoming, taking me into the countryside to tour traditional ger camps. I was lucky to experience some of the local Mongolian culture, including food and drink. The Mongolians eat a largely protein and fat-filled diet. I sampled goat boodog, a meal made by stuffing a goat's intestines with hot stones and cooking the carcass amidst hot coals with the skin and all. I drank traditional fermented mare's milk, ate horse stomach salad, and washed it all down with the ubiquitous Mongolian salt tea.

ABOVE: Ger Camps

BELOW: Goat Boodog
Almost a third of Mongolia's population still follows the traditional nomadic lifestyle; herding livestock and living in round, felt tents. Falls from horses are much more common in the countryside than motor vehicle accidents. The nomadic lifestyle greatly complicates access to orthopaedic care. A large number of injuries can go undiagnosed or untreated because of lack of education, and many patients suffer a devastating delay in treatment due to a lack of infrastructure. Much work still needs to be done in Mongolia, and many other countries around the world. I am happy that I was able to experience orthopaedics in this developing country, and know that this trip is only the first in hopefully many I will make during my career.

LEFT: Performing an operation with Dr. Jargalsaihan, Orthopaedic Trauma Director at the National Trauma and Orthopaedic Research Institute in Ulaanbaatar, Mongolia.

BELOW: Photo of me on a hike above Ulaanbaatar.

2009-10-12T06:53:00.000-07:00

Phnom Penh, Cambodia

The opportunity to work overseas is a highlight for many in Washington University's orthopaedic surgery residency training program.

Bethany Gallagher, M.D., a 2009 graduate of the residency program, traveled to Cambodia for her international experience.

The photo above is of Kossamak Hospital, a 3-story open-air facility without an elevator.

Ambulances that pulled up to the hospital did not have any monitors or lifesaving equipment in them.

Instead of providing food for the patients, the hospital provided open flames and hot plates at the patient's bedside. Entire families stayed at the patient's bedside providing nursing care (shown below to the left).

The cost of care differed immensely from treatment in the United States.

Cost of Care:
$0.50/day for sheets
$2.00/day semiprivate room
$7.00/day private room with TV
$20.00 CT scan

The Operating Room is shown to the left.

During Bethany's time in Cambodia, she treated fractured hips, femurs, tibias and missed compartment syndromes. The experience was life-changing for Bethany, as for many of the residents in the program.

Welcome!

2009-10-09T23:12:00.000-07:00

Welcome to the Washington University Department of Orthopaedic Surgery- Residency Training Program's travel blog.

The International Orthopaedic Surgery Experience

2009-10-09T12:51:00.000-07:00

Residents in our program have the opportunity to work oversees during a 2-week rotation. Residents have traveled to the following locations:

Bhutan - General Orthopaedics
Cambodia - General and Orthopaedic Trauma
China - Club Foot Deformities
France - Shoulder Surgery
India - Pediatric Orthopaedics
Myanmar - General Orthopaedics
South Africa - Joint Replacement