We received this email from Dr. Wardak last week and wanted to share. Dr. Wardak is the program manager for SIGN programs in Afghanistan. Randy Huebner, the founder of Acumed, has been putting together usable kits of plates and used external fixitors which we send onto SIGN programs in Afghanistan and other areas of the world. Dear Randy Huebner and SIGN Friends:
We are very happy to have anatomic plates as a donation system for National military hospital and other centers.
We are all promise to use it for poor in Afghanistan. No one believes that especially in Asia to have the standards of Mayo Clinic in Afghanistan. For this reason in attached pictures every one is holding an anatomic plate on their hands. We proud on our international friend’s; especially SIGN and Accumed.
Dr. Wardak is in the middle of the group-6th from the right.
Best Regards,
Col. Dr. M. Ismail Wardak
Member of OTA,SICOT&SIGN
Chair of International Relations
Of Afghan Orthopedic Socity
Chief of Orthopedic Trauma
National Military Hospital
Kabul Afghanistan
To learn more about Acumed and Randy Huebner, please check out their website www.acumed.net.
While I am slogging away in Kenya - waking up at 5:20am and working until after dark - Dr. Zirkle arrives in Bangladesh and also works long days. The pace there is the same as here in Kenya. Although I am getting work done, it seems to barely make a dent: finish three cases and five new traumas arrive, finish five cases and there are seven new operative cases in the clinic. The amount of work to be done is staggering. Everything is uphill.
Dr. Isidor putting our patient through his paces. This man had a chronic lunate dislocation - life was good post-op.
At the same time, hundreds of surgeons, medics, physiotherapists, CEO's, teachers, and even accountants are traveling with organizations to care for patients, run orphanages, keep books, and teach teachers. They are traveling with MSF, Unicef, The Peace Corps, SIGN, and hundreds of other organizations. They all have something in common. All of these people, I believe, strive for a greater level of equality among humans.
It is a giant quest and the climb seems unconquerable. I believe that it is not. Dr. Asle, an anesthesiologist from Norway, was amused by my energy and by my frustration when we met in Ethiopia. I am naive, he is wise. His thoughts are complex, mine are simple. He told me some words that I'll never forget. He likened the inequality in the world today to racial segregation in North America some 50-70 years ago. Our grandparents tolerated this behavior. Segregation seemed ok. Some people spoke out, but most did not though they knew it was wrong. They sat back quietly shaking their heads. Five decades later it seems proposterous that this occurred on North American soil less than two generations ago. Of course racial issues in the USA are far from solved but they have clearly come a long way in the short period of time. I am not sure that I have what it takes to affect change in the world (in fact I am quite sure I do not) but I am sure, as Dr. Asle, that I won't sit back and watch. I'll try and do my bit.
Squat and smile. This is a simple way to asses fracture healing for both the femur and the tibia. Squatting requires composite motion of the ankles, knees and hips, while smiling is a good indicator that the patient is pain free.
Some patients enjoying a rare break from the rain in Kijabe.
The street outside of Black Lion Hospital in Addis. The tarp on the right is 'higher-end' squatting. It is common to see a family arise from a five foot fort at sunrise. The streets are lined with people bunking down every night after dark. There are a rumoured 100,00 street kids in Addis Ababa. Staggering.
When dinner and warmth rely on having something to burn, one learns how to yield a machete at an early age. Kijabe, Kenya.
Home now. Thanks for reading. The End.
Dr. Neil. J. White
Some points of follow-up:
-Penina is recovering well from her surgery in Tanzania. The right hand is functioning better but she still complains with inner grip and full extension. Ken Moghadam and Steve Scott from Cascade Orthotis in Calgary have agreed to provide a free custom left arm prosthesis. Dr. Ryan Frank has agreed to assess Penina for facial surgery and if indicated, provide said surgery for free. All of this will take place during a two week visit to Calgary, Alberta, Canada for Penina and her mom. We are working on visas. They will billet with medical colleagues of mine (although I have not informed them yet --you know who you are!), and I just need to raise about $5,000 USD for flights.
-This is follow-up on a case I have not yet talked about. Before I left Ethiopia, I did a really tough case. I don't like taking on tough cases just before leaving--It does not seem right to be unable to follow these patients--a young man presented with a neglected open knee fracture dislocation.
We washed out the infection and then fixed the knee with small plates and a spanning fixator (I would never do this at home but was doing the best I could with what I had). The patellar tendon was completely ruptured off the tubercle and tied over a post. So, he did great. After I left Ethiopia for Tanzania his wound dehisced (broke open). Meanwhile, Dr. Sami Hailu had just returned from the SIGN conference. While in the USA, Dr. Sami went to the SIGN Flaps Course in San Francisco (this is a course where surgeons learn to cover wounds with local flaps - they do not have the support from plastic surgery that we get at home). He learned how to manage problems exactly like a dehisced wound about the knee. He emailed me to discuss this potentially catastrophic complication. His surgical plan was good, and after our discussion, he took this patient back to the OR and covered the knee wound with a medial gastroc flap. It worked.
It was Sami's first time doing that surgery (other than on a cadaver). Of course I was disappointed that our patient had this complication but was equally elated, however, that Sami had acquired the skills and executed a well thought out plan to rectify the problem. This was great for the patient and averted disaster. It was equally great for Dr. Sami to be given an opportunity to use his new skills so fresh off the course and to gain the associated surgical confidence. I am proud of him.
-Open Tibia Protocol: It looks like the Open Tibia Protocol will be starting at Black Lion Hospital in Addis during mid January. I think this has the potential to be groundbreaking for open fracture care in the developing world. We will aim for the stars with this project and, if at all possible, I will go back to facilitate and trouble shoot.
-The fasciocutaneous flap: I learned this from Dr. Duane Anderson in Soddo. We did one together and was then able to do three in Addis with the help of keen residents. I later received a letter from Dr. Geletaw (one of those residents) who has now done two successful fasciocutaneous flaps autonomously. This technique has averted major potential morbidity for those patients. It is nice to teach, it is nice to learn, it is especially nice to pass on knowledge and know that it is being passed on further.
Stiff elbows are a real problem all over the world. This can usually be prevented by appropriate intitial treatment. The operation to get the elbow moving is a big one - another tough problem. We operated on many stiff elbows.
-I logged 122 surgeries while away. I was pretty good at logging, but not perfect. This does not include simple debridements. I did 25 SIGN nails (including two FIN nails). I was most productive at Kijabe doing 39 cases in 12 operative days and also very prodictive at both sites in Ethiopia. At Bugando we managed only 17 cases in 15 potential operating days (I also logged 25 cases discussed and listed but not done due to lack of OR time). Including the complication described above, I know of three significant complications: wound dehiscence (described above), failed skin graft (revised with repeat graft), and radial nerve palsy from excessive traction during chronic shoulder dislocation (I have yet to hear if this has resolved).
I am sure there will be more complications, in fact I keep thinking there is another one but I can't seem to remember at the moment. Hopefully this will come back to me. We are a pointless profession without follow-up -- - - I remembered another complication (amazing how one tries to block out the bad) - in my final week in Kijabe I manipulated a stiff knee in a young nurse with neglected femur and tibia fractures. We had eradicated the femur infection and done a staged SIGN nail with cement spacer. She had less than five degrees of motion in the knee and I manipulated her to 60 degrees before re-breaking her tibia. I was very disappointed. She understood. I expect this low energy fracture will heal without consequence but it sure did not help her knee motion. This is a humbling profession.
There are many ways to fix broken bones. Most operations begin with the correct identification of the problem. If the diagnosis is not correct then it becomes very unlikely that the correct treatment will follow. The ultimate treatment is based on the surgeon's skill set and available materials. Many people with a fracture of the long bones of the leg - lets call them the femur and the tibia - don't walk again until the fracture is fixed. This is especially true for the femur. Please note that this is an over simplification of reality. You know when you travel to a third world country and you see beggars on the street with awkward limps and twisted legs? Much of that is a result of trauma. Many of those people held jobs before injury. Many were even injured at work. Most deformity from trauma is completely preventable with appropriate care. Nothing more than a blip in the patients life; not even important enough to remember the surgeon's name. A narrow miss.
The femur and tibia are hollow allowing for a slim rod of metal to be placed inside the bone for stabilization. There are many ways to insert the nail into the bone. The nail can be inserted with x-ray guidance, or by making a cut and looking directly at the bone and fracture. For x-ray guidance (the gold standard in North America), one must have a functional x-ray machine. This is rare in East Africa and most fractures are treated using an open SIGN technique. For closed treatment, a traction table also helps a great deal. This is a table that allows for a safe, constant pull on the leg, restoring its normal shape and allowing for easier passage of the nail.
The orthopaedic team putting a patient into traction. At home we use heaps of cotton padding and a whole roll of tape to secure the foot. Here, we use old running shoes and reusable ace bandages. This creative and cost effective innovation works every bit as well.
Typical set-up for closed femoral nailing. The patient's right leg is in traction and the placement of the crutch helps to align the fracture. By dropping the left leg low down (scissor position), the x-ray machine is clear for good images. Dr. Buckley (Calgary, Alberta) would be proud to see that the crutch transcends continental boundaries.
Three months ago I heard Dr. Tobias Otieno of Kijabe, Kenya talk at the SIGN Conference in Washington state, U.S. He presented his experience with closed SIGN nailing using an x-ray machine and fracture table. Today I fixed my first femur using his technique. Nime Sumbuca Sana (I struggled a lot). Tobias makes this look easy.
Sweat has been a challenge for me in the Kijabe OR's - hot rooms, hot lights, and lots of work. Post-operatively, you can see the real colour of my scrubs just below the knees - everything else is soaked. The headband is lined with absorbent gauze to prevent dropping sweat into the sterile field.
Kijabe is by far the most equipped hospital I have seen in East Africa. It is highly functional and efficient: good operating theatres, surgical nursing that is as good as it gets (anywhere in the world), and a huge stock of orthopaedic implants. Access? We do between 10 to 18 cases per day, bouncing from room to room and doing whatever is needed of us. An infectious team mentality exists here in Kijabe. This is a tertiary referral centre for the entire country.
Speaking of the entire country, all of the government employed doctors in Kenya are currently on strike. Here is an excerpt from yahoo news:
"One striking doctor, Dennis Miskellah, said that on his first day on the job at Kenyatta National Hospital he had to deliver a baby without gloves.
'Can you imagine, in this era of HIV and AIDS, we don't even have gloves at the country's biggest public hospital?' he asked. 'Sometimes we don't even have IV lines.'
Other doctors said their hospitals ran out of drugs for deadly illnesses like cholera or typhoid. Many said they knew of cases where patients had died because of the shortages.
'We doctors refuse to be used just to certify deaths,' said Miskellah."
Kijabe is always busy. At the moment it is just mental.
Compare two patients: the man with the above femur fracture was admitted to Kijabe on Monday, operated on Tuesday and home on Thursday. He will be seen in follow-up in six weeks and back to work in eight to ten weeks at the most. Jackson was in a similar motor vehicle crash and presented to Kenyatta Hospital on November 20 (largest hospital in the country). He had been lying in bed for three weeks waiting. Just waiting. He gave up on Kenyatta, raised some funds and traveled to Kijabe for care. He will get this care. He represents hundreds of patients who are not so lucky to find their way here.
Kijabe is situated on the edge of Kenya's Rift Valley. Beautiful views, hiking and biking all around.
Kijabe is a private mission hospital with a clear goal of providing care to the poor. Providing care for free, however, is not an option. The hospital must be at least somewhat self-sustaining. Patients generally need to pay for the disposable goods that they use - gauze, medicines, bandages, needles, IV lines, and such. Kijabe is always looking to lower the cost to the patient. Surgical supplies are largely donated. SIGN gives the nails for free which means surgeons like Tobias can fix these long-bone fractures at a very low cost to the patient. A short hospital stay also helps to reduce cost. Surgeons volunteering to work for free, of course, also lowers the cost.
Rich Davis is one of those surgeons - a general surgeon. He moved from Los Angeles with his wife and three children five years ago. He works in Kijabe, Kenya and his family is growing up in Kijabe.
One month after arriving in Kenya, Dr. Rich was playing on the monkey bars with his kids and he lost his grip (showing off I suspect). The fall resulted in a tibial fracture. He tells that the pain was unbearable with every movement and he couldn't imagine the agony of lying around waiting for care. Rich is now the proud owner of one shiny SIGN nail. He had surgery at Kijabe four years and 11 months ago - can you tell which side?
The Kijabe facility is made up of three groups: Local surgeons like Tobias, Long Termers like Rich, and Short Termers like myself. Everyone pitches in and everyone is here because they want to be. Last night, the ortho on-call team was very busy. Dr. Rich called me up and offered to be my 'scrub nurse' so we could do a case together and help unload the team's burden. By doing this we were all in bed by 11:00pm instead of half of the team up until 2:00am.
Kijabe is not solving the worlds problems. Kijabe is helping as many people as possible with the available resources and teaching the local physicians and trainees what is possible. This is a pretty good start. It reminds me of the hummingbird story. The world needs more hummingbirds.
Swahilli is the most common language of both Kenya and Tanzania. There are many ways to greet people in Swahilli: 'Jambo' is probably the most common - it means 'Hey'. 'Mambo' is my second favorite greeting. The direct translation is 'things', which is short for 'how's things?' The response is generally 'Poa' (cool) or 'safi' which means 'clean' or 'in order'.
Tanzania is full on Swahilli and most people do not speak fluent English. Most Kenyans however speak excellent English and as a result, 'Shang' - this is Slang Swahilli mixed with many English words.
Oh yeah - my favorite greeting is 'Shikamoo'. This is a universal greeting to an elder or an authority figure. It offers respect. The response is 'Marahaba', which acknowledges the respect. The literal translation: 'I clasp your feet'...'by all means'.
The women in Tanzania swathe their babies on their backs and carry their goods on their heads. I think this may be more physiologic than knapsacks.
I am now in Kijabe, Kenya on the southern part of the Rift valley. On the day I left Mwanza City, the newspaper headline read: '50 years of Tanzanian independence and Bugando Hospital has no oxygen'. The negative publicity appears to have at least temporarily solved the oxygen shortage.
We did 3 cases in my final week. I like very much operating with Isidor - we laugh a lot because we are both terrible assistants. It was bitter sweet, however, because we had so much to learn from each other, but managed to do so few cases together.
Rickets: Severe knocked knees likely caused by malnutrition. Before and after surgery.
My flight to Nairobi was cancelled so I traveled overland from Mwanza to Kenya. This took me through the Plains of Serengeti and the Ngorongoro Crater. If you have the means, I truly recommend this as a must do, once in a lifetime experience. Unforgettable.
It is impossible to encompass the Serengeti in a few pictures. No words to explain either.
Last week a pediatric resident from Northwestern arrived at the Bugando guest house. On her second or third day she lost a four week old kid in the neonatal intensive care unit. No oxygen. The kid stopped breathing. No urgency for resuscitation. No oxygen for resuscitation. She said that the kid would have lived if in North America. The worst part - no one told the mother. She just walked to the bedside to find her newborn baby dead. I am not sure why I tell this story - my goal is not to be sensational or dramatic. I just want you to understand that the problem in Mwanza is systemic. It is complex and will not be fixed overnight. Many of the hospital workers have resigned themselves to this and they know it is not right, but they need to get through the day. I guess I am telling this story because I want you to understand how truly different things are here, to understand how badly change is needed.
After the crater I took public transit from Karatu to Arusha on my way to Nairobi. This was an experience. On a minibus (Dala dala) with 16 seats including the driver. I counted as many as 27 passengers at one time. There were also two goats and two chickens. The road was 140 km - we made more than 20 stops and although I lost count, there were more than 50 different people on and off the bus. At one point I had a Maasai tribal elder sitting on my lap. I said, "Shikamoo". He smiled. I also had a cute kid on my lap for about 30 km's while the chickens were on the floor behind me pecking at my heels. Everyone was coughing. No seat belts - sorry mom. Oddly, I enjoyed this experience. I was the only Mzungo.
From Arusha, I took and express bus to Nairobi and then a hired car to Kijabe. The whole adventure took four days and my stuff only got soaked twice.
Mwanza City is physically very beautiful. I found it really odd to see such poor people with waterfront views. Mud huts built on what would be million dollar property elsewhere.
Isidor, Nkenda, and Daas were great hosts and are great surgeons with high aspirations. They want to have a residency program for orthopaedics and are all great teachers. Unfortunately, at the moment they can not rely on Bugando hospital to deliver the basics that they need. I am not sure of the problem, but the hospital has great difficulty delivering care. I would be naive to think that this is purely based on limited resources - I would like to be blunt, but for political reasons, I can not say what is on my mind. This drives my blood pressure high. Too high. What happens to the money going in is unclear, but it is clear to me that providing care is not the top priority. I feel for the people who work there because so many aspects of their job, and their desire to care for patients is just out of there control.
The positives of my month were the meeting of great friends in Mwanza: Isidor, Nkenda, Daas and many many others.
Doctors Jan, Gerald, Isidor, Nkenda and I took a weekend trip to Rubondo Island. Another Tanzanian Gem. We enjoyed the countryside, wild animals and company.
There was no shortage of joking around, but also some serious talks about the current situation of health care in Tanzania.
Needs assessment is an important part of progress and I spent many hours searching for solutions. Dr. Chacha is a young general surgeon who is opening a private hospital with his father. They are keen to take care of the rich and the poor and to do outreach to impoverished areas. Chacha is very keen to work with SIGN. There is another hospital built, but not opened, that we are looking to turn into a missionary style private hospital for the poor - this is a great formula similar to Kijabe and to Soddo, but it needs some pretty serious financial backing.
Getting great care in Mwanza today often means leaving the country. Ironically, the doctors and surgeons are incredibly capable of providing this care. They need to be in a system that supports their efforts and hears their voices. I hope we have at least planted some seeds to initiate change.
With all the free time, I was able to teach medical students, interns and residents. Here I am in front of a class of 150 and if you know me, the sparkle in the eye tells you I am clearly spinning some tale or making an emphatic point. The students were attentive and interactive - it was a pleasure.
On my way home from the hospital I saw a tiny kid walking out from the HIV clinic. He was wide eyed at the site of Mzungo (white guy) so I chased him around for a bit. We were both giggling. I realized that I was in a good mood, the first in a while. What kind of person is in a good mood because they were allowed to cut into someones skin? I suppose an axe murderer or a surgeon. Finally some cases - we had a good day.
In the morning I operated with Dr. Daas (the senior man here). I'll tell you a bit about Daas and then about the surgery. He is trained as a general surgeon, but until the last five years had been doing all of the orthopaedics for this catchment of 3 million. He picked up many things along the way and spent time in Switzerland and in the U.S. He is an excellent and thoughtful surgeon. He demonstrates tremendous compassion.
Penina Josia - I love this kid. A ten year-old in a horrific bus crash just over two years ago. She was traveling on vacation with her mom when the bus lost control and rolled to its side before sliding off the road. The window was open. Penina lost her left arm and had severe facial injuries. She also had a terrible injury to the right hand causing scarring and contracture of the tendons. Daas put her face back together after the crash. Today we did a contracture release and repaired some tendons to try and get the right hand functioning better - I am optimistic this will work. Once again I was able to depend heavily on the opinions of my mentors back home.
Penina has some toughchallenges ahead. I have gotten to know her and her parents pretty well. I am sure they are up for it.
Opportunity is heavily weighted against physical disability. Social services are scarce. This weight is much heavier for women - recurring themes. The people of this country do amazing things with what they have.
Next I went with Dr. Isidor to the private hospital. I think it is important to understand the difference between private hospitals and public hospitals in the Lake Zone of Tanzania. I don't yet understand this difference myself. I do know this - the public hospital has a tough time delivering care due to lack of resources while the private hospital will accommodate surgery at anytime. Patients pay for surgery at both setups and the cost to the patients is not necessarily very different. In this time without oxygen at Bugando, the private hospital has allowed us to at least get some work done.
I am washing my hands at one of the private hospitals. A standard bar of soap and a long cold water scrub. I like this picture. I am not sure why.
We operated on a six month-old boy born with a rare condition called amniotic band syndrome. Basically he was born with some missing and webbed fingers on the left hand and the long, ring and small fingers stuck together on the right. This is due to some poorly understood mechanical problems in the womb. This occurs in about 1 in 1,500 to 1 in 15,000 live births.
The right hand will certainly be his best hand long-term but we are optimistic to improve function in both.
Dr. Isidor and I operated on 3 limbs. It was great to finally work.
We operated on three limbs over five hours. This was a cool case to do here because it requires two stages. Dr. Isidor assisted and did major components of the case. He will do the second stage alone in about three or four months. I have every confidence in him that this will go well. We separated out most fingers and released a constriction band around the right ankle. I think we have made this kid much better both functionally and cosmetically. I will be unlikely to get long-term follow-up - recurring themes.
The right hand after separation of fingers. This will grow to be a good hand - Not perfect, but good.
After surgery we casted both upper limbs. This is to prevent the child from sucking on his wounds. Pretty cute.
The problems of last week did not disappear. These cases were the only two I did this week. I spent more than 25 hours waiting and pushing and trying - broken record. No oxygen on Friday or the weekend. Two kids died in the ICU because you can only manually bag someone without oxygen for so long. These kids easily could have lived. Oxygen. Oxygen. Oxygen is not the only problem. If it is not the oxygen then it is the gauze. If not the gauze then drapes. If not drapes then something else. The problem is systemic and goes much deeper than oxygen. We must not lose hope and we must remain frustrated.
Penina and her mom on the day of discharge. She is a tough kid and a great patient.
Penina is a special kid (still on my mind). I am not sure why I am programmed the way I am, but I seem to really feel this stuff. She is an intelligent kid with a good family and some tough times ahead. I am working to find her a plastic surgeon - not sure if you can see her smile as I do, but it is a winner. I am also looking for a left arm, a prosthetic. I asked everyone I could think of and have no shame asking everyone else by way of this blog.
SIGN Fracture Care is an orthopaedic humanitarian aid organization treating impoverished people in developing countries. SIGN supplies surgical implants and training to orthopaedic surgeons at no cost providing that the care to the patient is also free.
SIGN has started programs in more than 200 hospitals throughout 48 developing countries. More than 4,000 SIGN surgeons use the SIGN system on a daily basis to repair fractures largely caused by road traffic accidents. Since 1999 more than 75,000 patients have been treated with the SIGN system. As we spread throughout the developing world and broaden the fixation devices we offer, we continue to hold fast to our vision of creating equality of fracture care throughout the world.
