Zimbabwe

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.

Tanzania

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.

Blantyre, Malawi

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.